Drugs in Pediatric Cardiology 

Based on the article:  The Pediatric Cardiology Pharmacpoeia

By: Ra-id Abdulla, Sharon Young and Steve Barnes

Published in Pediatric Cardiology (1997) Volume: 18, Issue:  3

 

 

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Inotropic and Vasopressor Agents

Antiarrhythmic Agents

Vasodilators

Diuretic Agents

Drugs Used in Cardiac Emergencies

Sedatives

Miscellaneous


Inotropic and Vasopressor Agents

Amrinone

Calcium Chloride

Calcium gluconate

Digoxin

Dobutamine

Dopamine

Epinephrine HCl

Milrinone

Phenylephrine HCl

Norepinephrine

Antiarrhythmic Agents

Adenosine

Amiodarone

Atenolol

Bretylium Tosylate

Disopyramide

Esmolol

Flecainide

Lidocaine

Phenytoin

Procainamide

Propafenone

Propranolol

Quinidine

Tocainide

Verapamil

Vasodilators

Captopril

Diazoxide

Enalapril

Hydralazine

Metoprolol

Nifedipine

Nitroglycerine

Nitroprusside

Prazosin HCl

Diuretic Agents

Bumetanide

Chlorothiazide

Ethacrynic Acid

Furosemide

Hydrochlorothiazide

Metolazone

Spironolactone

Drugs used in cardiac emergencies

Atropine

Diphenhydramine

Bretylium Tosylate

Calcium Chloride

Epinephrine Hydrochloride

Lidocaine

Sodium Bicarbonate

Pancuronium

Vecuronium bromide

Sedatives

Chloral Hydrate

Chlorpromazine

Diazepam

Fentanyl

Ketamine

Meperidine

Midazolam

Morphine sulfate

Naloxone

Promethazine

Miscellaneous

Acetylsalicylic Acid

Ammonium Chloride

Argeninine HCl (10%)

Dexamethasone

Heparin

Ibuprofen

Indomethacin

Isoproterenol

Prostaglandin E1

Protamine sulfate

Streptokinase

Tolazoline HCl

Urokinase

Vitamin K (phytonadione)

Warfarin

 

 

Inotropic and Vasopressor Agents

Amrinone

Inocor

Onset: 2-5 minutes

Mode of action: Myocardial cAMP phosphodiesterase inhibitor, increase intracellular cAMP resulting in better myocardial function, pulmonary and systemic vasodilation

Route

Dose

Frequency

Infusion Load: 0.5 mg/kg

may be repeated Q20 min

Maintenance: 5-20 mcg/kg/min

 
Side effects: Arrhythmia, thrombocytopenia

Caution: Bleeding disorder, hypertrophic cardiomyopathy, hypotension

 

Calcium Chloride
Onset: rapid

Mode of action: Enhances contractility through regulation of action potential

Route

Dose

Frequency

IV Hypocalcemia:

10-20 mg/kg

Q10 min
Side effects: Bradycardia, hypotension, peripheral vasodilation, hypercalcemia, hypermagnesemia, hyperchloremic acidosis

Caution: Central venous line administration ONLY. Max. conc. is 20 mg/ml infusion Extravasation may lead to tissue necrosis, use local hyaluronidase if occur, may precipitate arrhythmia in digitalised patient

Contraindication: Hypercalcemia, ventricular fibrillation

 

Calcium Gluconate
Onset: Rapid

Mode of action: Enhances contractility through regulation of action potential

Route

Dose

Frequency

PO, IV Hypocalcemia:

50-125 mg/kg, max = 4 g

QID
Side effects: Bradycardia, hypotension, peripheral vasodilation, hypercalcemia, hypermagnesemia

Caution: Central venous line administration ONLY. Max. conc. is 20 mg/ml infusion Extravasation may lead to tissue necrosis, use local hyaluronidase if occur, may precipitate arrhythmia in digitalised patient

Contraindication: Hypercalcemia, ventricular fibrillation

 

Digoxin

Lanoxin, Lanoxicaps

Onset: PO: 1-2 hr, IV: 5-30 min

Mode of action: Inhibition of Na+-K+ pump resulting in increase Ca++ intracellular influx

Route

Dose

Frequency

PO Loading:

10 mcg/kg

max = 375 mcg

Maintenance:

5 mcg/kg, max = 125 mcg

Premature infants should receive 1/2 loading and maintenance doses.

Q6hr X 4
IV 75% of PO doses BID
Side effects: Sinus bradycardia, AV block, fatigue, headache, nausea, anorexia, neuralgias, blurred vision, photophobia

Caution: Renal failure. Cardioversion or calcium infusion may cause VF in patients receiving digoxin (pretreatment with Lidocaine may be helpful).

Therapeutic level: 0.8-2 ng/ml, not reliable in neonates, since they may have falsely elevated levels (due to maternal digoxin like substances in serum)

Contraindication: Ventricular arrhythmia, AV block, IHSS, constrictive pericarditis

 

Dobutamine

Dobutrex

Onset: Rapid

Mode of action: stimulates beta adrenergic receptors, resulting in increase myocardial contractility and heart rate

Route

Dose

Frequency

Infusion 2-20 mcg/kg/min

max = 40mcg/kg/min

 
Side effects: Ventricular arrhythmias, hypertrophic cardiomyopathy, tachycardia, hypertension, angina, palpitation, headache

Caution: Patient should be euvolemic.

Contraindication: IHSS, tachycardia, arrhythmias, hypertension

 

Dopamine

Intropin

Onset: Rapid

Mode of action: Through norepinephrine by stimulating adrenergic and dopaminergic receptors, selective renal vasodilation

Route

Dose

Frequency

Infusion Renal dose:

2-5 mcg/kg/min

Inotropic dose:

5-15 mcg/kg/min

 
Side effects: Tachyarrhythmias, premature beats, hypertension, headache, nausea

Caution: Correct hypovolemia. Extravasation will cause tissue necrosis, phentolamine should be infiltrated around the extravasation to minimize necrosis. Do NOT use discolored solution, high doses (>15 mcg/k/min causes decrease renal perfusion.)

Contraindication: Infusion through UAC, pheochromocytoma, ventricular fibrillation.

 

Epinephrine HCl

Adrenaline

Onset: 1-5 minute

Mode of action:

Inotropy: beta adrenergic receptor stimulation

Vasoconstriction: alpha adrenergic receptor stimulation

Route

Dose

Frequency

IV, ETT Bradycardia/hypotension: 1:10,000

0.1 ml/kg

Q 3-5 min
Infusion 1-10 mcg/kg/min Q3-5 min
Side effects: Tachy-arrhythmias, hypertension, headache, nervousness, nausea, vomiting, decrease renal flow

Caution: Hyperthyroidisim, hypertension, arrhythmias. Do Not use discolored solution. Extravasation will cause tissue necrosis, phentolamine should be infiltrated around the extravasation to minimize necrosis

Contraindication: Acute coronary artery disease, angle closure glaucoma

 

Milrinone

Primacor

Onset: Rapid

Mode of action: Myocardial cAMP phosphodiesterase inhibitor, increase intracellular cAMP resulting in better myocardial function, pulmonary and systemic vasodilation

Route

Dose

Frequency

Infusion Load:

50 mcg/kg, over 10-15 min

Maintenance:

0.1-1 mcg/kg/min

 
Side effects: Arrhythmia, headache, hypotension, thrombocytopenia rarely reported.

Caution: Renal dysfunction

Contraindication: Severe pulmonary or aortic obstructive disease

 

Phenylephrine HCl

Neo-synephrine

Onset: Rapid

Mode of action: Alpha adrenergic receptors stimulant

Route

Dose

Frequency

IV 5-20 mcg/kg , max = 0.5 mg Q10-15 min
Infusion 0.1-0.5 mcg/kg/min,

max = 4 mcg/kg/min

 
Side effects: Tremor, insomnia, palpitation, hypertension, angina, excitability, headache, tremors, bradycardia

Caution: Hypertension, hyperthyroidism, arrhythmia, hyperglycemia. Extravasation will cause tissue necrosis, Phentolamine should be infiltrated around the extravasation to minimize necrosis.

Contraindication: Pheochromocytoma, severe hypertension, ventricular tachyarrhythmias, severe coronary artery disease

 

Norepinephrine

Levophed

Onset: Rapid

Mode of action: Stimulates alpha and beta adrenergic receptors (predominantly alpha effect)

Route

Dose

Frequency

Infusion 0.05-0.1 mcg/kg/min,

max 2 mcg/kg/min

 
Side effects: Arrhythmias, palpitation, hypertension, angina, headache, anxiety, vomiting, uterine contractions, respiratory distress, diaphoresis.

Caution: Hypertension, arrhythmia, occlusive vascular disease. Extravasation will cause tissue necrosis, Phentolamine should be infiltrated around the extravasation to minimize necrosis.

Contraindication: Pheochromocytoma, severe hypertension, ventricular tachyarrhythmias, severe coronary artery disease

 

Antiarrhythmic Agents

Adenosine

Adenocard

Onset: Very rapid

Mode of action: Slows AV node conduction.

Route

Dose

Frequency

IV, rapid push 0.1 mg/kg

Increase by 0.05 mg increments every 2 min to a max of 0.25 mg/kg,

max = 12 mg/dose

Rapid IV push Q2 min PRN
Side effects: Palpitations, flushing, headache, dyspnea, nausea, chest pain, lightheadedness, bradycardia.

Caution: Bronchospasm in asthmatics

Contraindication: AV block or sick sinus syndrome, unless pace maker placed

Drug interactions: Potentiates effects of dipyridamole. Carbamazepine may increase heart block. Theophylline antagonizes effect of adenosine.

 

Amiodarone

Cordarone

Onset: 3 d - 3 wk

Mode of action: Class III, inhibits alpha and beta adrenergic receptors, prolongs action potential and refractoriness

Route

Dose

Frequency

PO Loading:

10-15 mg/kg

max = 1600 mg

Maintenance: 2.5-5 mg/kg, max = 800 mg

QD X 7-14 d
Infusion Load: 5-7 mg/kg

over 20-30 min

maintenance: 1-2 mg/kg/hr or 10-20 mg/kg/d

QD
Side effects: Long half life. Pulmonary fibrosis, alters thyroid (hypothyroidism) and liver dysfunction. Worsening AV block and bradycardias. Anorexia, nausea, vomiting, dizziness, paresthesia, ataxia and tremor, corneal deposits, blue discoloration of skin, photosensitivity.

Caution: Increases digoxin (reduce dose by 1/2), warfarin, flecanide, procainamide, quinidine and phenytoin serum levels, thyroid disease

Therapeutic level: 0.5-2.5 mg/L

Contraindications: AV block, sinus node dysfunction, sinus bradycardia

 

Atenolol

Tenormin

Onset: 60-120 min

Mode of action: Class II antiarrhythmic agent, long acting selective b Blocker.

Route

Dose

Frequency

PO 0.8-2 mg/kg QD
Side effects: Hypoglycemia, hypotension, nausea, vomiting, depression, weakness, less bronchospam than propranolol, heart block, bradycardia, negative inotropic effect

Caution: CHF, adjust dose in renal failure.

Contraindication: Cardiogenic shock, pulmonary edema

 

Bretylium Tosylate

Bretylol

Onset: IV: 6-20 min, IM: < 2 hr

Mode of action: Class III antiarrhythmic agent, sodium channel blocker, inhibits norepinephrine release

Route

Dose

Frequency

IV, IM 5 - 10 mg/kg QID
Side effects: Hypertension followed by hypotension, PVC, arrhythmias, increased sensitivity to digitalis and catecholamines, nausea, vomiting, vertigo, confusion, lethargy.

Caution: Pulmonary hypertension, aortic stenosis, renal dysfunction

Contraindication: Digitalis induced arrhythmias

 

Disopyramide

Norpace

Onset: Minutes

Mode of action: Class Ia antiarrhythmic agent , sodium channel blockers depresses myocardial excitability

Route

Dose

Frequency

PO 2.5-5 mg/kg QID
Side effects: Negative inotropic effect, prolong QRS and QT durations, ventricular arrhythmias, anticholinergic effect (dry mouth, urinary retention, constipation), nausea, vomiting, hypoglycemia, cholestasis, syncope.

Caution: Already prolonged QRS or QT durations, CHF, renal dysfunction

Contraindication: Already reduced myocardial contractility, AV block

Drug interactions: Increase Disopyramide effect: erythromycin due to decrease in metabolism. Decrease Disoparymide effect: Hepatic inducing agents, phenobarbital, phenytoin, rifampin.

 

Esmolol

Brevibloc

Onset: Rapid

Mode of action: Class II. Selective b1 blocker.

Route

Dose

Frequency

Infusion Loading:

0.5 mg/kg

Maintenance:

50 mcg/kg/min, increase by 50 mcg/kg increments to a max. of 300 mcg/kg/min. Reload with each increase. Titrate to effect.

over 1 min.
Side effects: Hypoglycemia, hypotension, nausea, vomiting, depression, phlebitis, bronchospam at higher doses, heart block, bradycardia, negative inotropic effect

Caution: Skin necrosis may occur with extravasation, max. conc. : 10 mg/ml due to hyperosmolarity. May increase digoxin or theophylline serum levels

Contraindication: Cardiogenic shock, heart block, severe asthma

 

Flecainide

Tambocor

Onset: Rapid

Mode of action: Class Ic antiarrhythmic agent, sodium channel blocker, cell membrane depression

Route

Dose

Frequency

PO 1-2 mg/kg

max = 100 mg

TID
Side effects: Negative inotropic effect, arrhythmias, rash

Caution: Heart failure, heart block, Hepatic impairment, reduce dose by 25-50% in renal failure

Contraindication: 2nd or 3rd degree AV block

Therapeutic level: 0.2-1 mcg/ml

 

Lidocaine

Xylocaine

Onset: Rapid

Mode of action: Class Ib antiarrhythmic agent, sodium channel blocker , local anesthetic depressing myocardial irritability

Route

Dose

Frequency

IV 0.5-1.0 mg/kg repeat after 5 min., PRN
Infusion 20-50 mcg/kg/min  
Side effects: Hypotension, shock, nausea, seizures, respiratory depression, anxiety, euphoria, drowsiness, agitation

Caution: Hepatic disease, heart failure

Contraindication: AV block

Therapeutic level: 2-5 mcg/ml

 

Phenytoin

Dilantin

Onset: Minutes

Mode of action: Not well defined

Route

Dose

Frequency

PO 2.5-5 mg/kg BID
IV

(Arrhythmia dose)

Load: 1.25 mg/kg

Maintenance: 2.5-5 mg/kg, max: 250 mg

BID
     
Side effects: Gingival hyperplasia, hirsutisim, exfoliative dermatitis, osteomalacia, ataxia, drowsiness, blood dyscrasias, SLE like syndrome, Stevens-Johnson syndrome, peripheral neuropathy, lymphadenopathy, hepatitis, nystagmus, hypotension, bradycardia, folic acid deficiency.

Caution: Oral absorption reduced in neonates, serum levels are increased by cimetidine, chloramphenicol, INH, sulfonamide, trimethoprim. Rapid injection may cause hypotension and bradycardia

Contraindication: Heart block or sinus bradycardia

 

Procainamide

Pronestyl, Procan SR

Onset: IV: Rapid PO: 2-4 hr, IM: 10-30 min

Mode of action: Class Ia antiarrhythmic agent, Sodium channel blocker depressing myocardial excitability and conduction

Route

Dose

Frequency

PO 4-12 mg/kg

max = 1g

Q3-6 hr
IV Load:

5-15 mg/kg

max = 100 mg

Over 30 min
Infusion Maintenance:

20-80 mcg/kg/min,

max = 6 mg/min.

 
Side effects: Hypotension, Prolongs QRS and QT durations, SLE like symptoms, fever, positive coomb's test, thrombocytopenia, rash, myalgia, arrhythmias, GI symptoms, confusion.

Caution: Toxicity when QRS > 0.2 sec.

Therapeutic level: 4-10 mg/L of procainamide, or 10-30 mg/L of procainamide and NAPA levels combined.

Drug interactions: PA and NAPA levels are increased with: cimetidine, ranitidine, amiodarone, Beta Blockers, trimethoprin. Anticholinergic agents enhance effect.

Contraindication: Myasthenia gravis, complete heart block.

 

Propafenone

Rhythmol

Onset: Rapid

Mode of action: Class Ic antiarrhythmic agent, also blocks sodium channels and b Blocker effect

Route

Dose

Frequency

PO 2-3 mg/kg TID
IV 1-2 mg/kg  
Infusion 4-8 mcg/kg/min  
Side effects: AV block, palpitations, bradycardia, CHF, conduction disturbances, dizziness, drowsiness, dry mouth, altered taste, dyspnea, flatulence, blurred vision, dyspepsia

Caution: recent MI, CHF, hepatic or renal dysfunction

Contraindication: cardiogenic shock, bronchospastic disorder, conduction disorder

 

Propranolol

Inderal

Onset: PO: 40-120 min., IV: Rapid

Mode of action: b blocker, class II anti-dysrhythmic agent

Route

Dose

Frequency

PO 0.5-1 mg/kg QID
IV

(over 10 min.)

0.01-0.15 mg/kg,

max = 1 mg/dose

QID, PRN
Side effects: Hypo or hyperglycemia, hypotension, nausea, vomiting, depression, weakness, bronchospam, heart block, bradycardia, negative inotropic effect

Caution: In lung disease, heart, hepatic or renal failure. Barbiturates, rifampin or indomethacin will increase clearance, cimetidine, hydralazine, chlorpromazine, or verapamil cause decrease in clearance and enhanced effect.

Contraindication: Asthma. cardiogenic shock and heart block

 

Quinidine
Onset: Gluconate: IV 30-60 min., PO 4-8 hr. Sulfate: 1 hr

Mode of action: Class Ia anti-dysrhythmic agent, sodium channel blocker, depressing atrial and ventricular excitability. Vagolytic.

Route

Dose

Frequency

PO Gluconate: 4-10 mg/kg, max. = 600 mg TID
  Sulfate: 6 mg/kg

max = 600mg

QID
IV , IM Gluconate: 2-10 mg/kg

max = 400 mg

Q3-6 hr, PRN
Side effects: GI symptoms, hypotension, tinnitus, thrombotic thrombocytpenic purpura, rash, heart block, blood changes, widen QRS complex, prolongs QT, ventricular arrhythmia, thrombocytopenia, anemia

Caution: Toxicity is indicated by QRS interval >0.02 sec. Causes increase of Digoxin serum level (reduce digoxin by 1/2). Quinidine's effect is enhanced by amiodarone or Cimetidine. Quinidine's effect is reduced by rifampin, phenytoin or barbiturates. Atrial flutter may conduct 1:1 when quinidine is used alone, due to enhancement of AV conduction.

Therapeutic level: 2-7 mg/L

Contraindication: AV Block

 

Tocainide

Tonocard

Onset: 10-20 min.

Mode of action: Sodium channel blocker , local anesthetic depressing myocardial irritability

Route

Dose

Frequency

PO 9-13 mg/kg

max = 700 mg

TID
Side effects: Rash, nausea, arrhythmias, dizziness, vertigo, blood changes

Therapeutic level: 4-10 mcg/ml

 

Verapamil

Isoptin, Calan, Verelan

Onset: PO: 60-120 min., IV: Rapid

Mode of action: Class IV Calcium channel blocker

Route

Dose

Frequency

PO 1.5-3.5 mg/kg

max = 160 mg

TID
IV

over 2-3 min

< 1 yr: 0.1-0.2 mg/kg,

> 1yr: 0.1-0.3 mg/kg

max = 5 mg/dose

Q30 min PRN

If stable:

TID, BID

Side effects: Negative inotropic effect, constipation, hypotension, dizziness, fatigue

Caution: Extreme caution in infants and in WPW, may cause apnea, bradycardia, or hypotension. Do not use with other negative inotropes (e.g. beta-blockers). To reverse hypotension use calcium, isopreternol and IV volume. Reduce digoxin by 1/3 to 1/2.

Contraindication: CHF, hypotension, shock, AV block, right to left shunt lesions, atrial fibrillation, sinus bradycardia

Drug interactions: May increase serum level of digoxin, quinidine, carbamazepine, cyclosporin. Phenobarbital and rifampin may increase metabolism of verapamil.

 

Vasodilators 

Captopril

Capoten

Onset: 15-30 min

Mode of action: Angiotensin converting enzyme inhibitor

Route

Dose

Frequency

PO Neonates:

0.05-0.1 mg/kg

TID
  Infants & children:

Initially: 0.15-0.3 mg/kg, then titrate to a max of 2 mg/kg

TID
  Adolescents & adults:

12.5-25 mg, increase weekly by 25 mg/dose

max = 150 mg/dose

TID
Side effects: Hypotension, rash, proteinurea, neutropenia, tachycardia, cough, diminution of taste, reduce aldosterone production causing increase potassium renal absorption causing hyperkalemia

Caution: Adjust with renal dysfunction, administer 1 hr. prior to meals.

Drug interactions: NSAIDs, e.g. indomethacin, may decrease the antihypertensive effect of captopril. Potassium sparing agents will potentiate hyperkalemic effect

 

Diazoxide

Hyperstat

Onset: Rapid

Mode of action: vasodilator

Route

Dose

Frequency

IV, rapid injection over 30 seconds 1-3 mg/kg

max = 150 mg

Q5-15 min PRN,

then Q4-24 hr

Side effects: Hyponatremia, salt and water retention, arrhythmia, hypotension, GI disturbances, ketoacidosis, rash, hyperuricemia, hyperglycemia, flushing, tachycardia, dizziness, phlebitis

Caution: Diabetes mellitus, renal or hepatic disease

Contraindication: Coarctation of the aorta, AV shunts, dissecting aortic aneurysm

 

Enalapril

Vasotec

Onset: PO: 30-60 min, IV: 10-15 min

Mode of action: Angiotensin converting enzyme inhibitor

Route

Dose

Frequency

PO 0.1 mg/kg

max. 40 mg/day

QD, BID
IV, slow over 5 min 5-10 mcg/kg

max. 1.25 mg

QID
Side effects: Nausea, diarrhea, headache, dizziness, hypotension rash, diminishing of taste, neutropenia, hyperkalemia, hypoglycemia, chronic cough

Caution: Reduce dose in renal failure

Drug interactions: NSAIDs, e.g. indomethacin, may decrease the antihypertensive effect. Potassium sparing agents will potentiate hyperkalemic effect.

 

Hydralazine

Apresoline

Onset: PO: 10-30 min, IV: 5-20 min

Mode of action: peripheral vasodilator

Route

Dose

Frequency

PO 0.3-1.5 mg/kg

max = 25 mg

BID, QID
IV, IM 0.1-0.2 mg/kg

max = 20 mg

Q4-Q6 hr
Side effects: SLE like syndrome(reversible), palpitation, flushing, rash hematological changes. Hypotension, tachycardia, headache, anorexia, nausea

Caution: Severe renal failure and cardiac disease, CVA

Contraindication: Coronary artery disease, dissecting aortic aneurysm, mitral valve rheumatic heart disease

 

Metoprolol

Lopressor

Onset: 15-30 min.

Mode of action: b adrenergic receptor blockade

Route

Dose

Frequency

PO 0.5-2.5 mg/kg,

max = 225 mg

BID
IV 0.1-0.3 mg/kg, over 1 hr  
Side effects: Hypoglycemia, hypotension, nausea, vomiting, abdominal pain, CNS symptoms (depression, weakness, dizziness) bronchospam, heart block, bradycardia, negative inotropic effect

Caution: In lung disease, heart, hepatic or renal failure.

Drug interactions: Barbiturates, rifampin will increase clearance of metoprolol. Metoprolol metabolism decreases with cimetidine, amiodarone, diltiazem, propafenone, quinidine, hydralazine, chlorpromazine, or verapamil.

Contraindication: Asthma, heart block with concurrent use of verapamil

 

Nifedipine

Adalat, Procardia

Onset: PO 20-30 min, Sublingual 1-5 min

Mode of action: Calcium channel blocker

Route

Dose

Frequency

PO, sublingual 0.25-0.5 mg/kg

max. = 10 mg

TID, QID
Side effects: Hypotension, flushing, tachycardia, headaches, dizziness, nausea, palpitation, bone marrow suppression, arthralgia, shortness of breath

Caution: Heart failure, aortic stenosis.

For sublingual administration: puncture capsule and express fluid sublingually.

(conc = 10 mg per 0.34 ml)

 

Nitroglycerine

Tridil, Nitro-Bid

Onset: Rapid

Mode of action: Vasodilation, venous more than arterial

Route

Dose

Frequency

Infusion Initial:

0.25-0.5 mcg/kg/min

Then: 0.5-10 mcg/kg/min,

usual dose 1-3 mcg/kg/min

 
Ointment 1-2 cm Q2-4 hours
Side effects: Flushing, headache, hypotension, tachycardia, nausea, perspiration, tolerance

Caution: Increase ICP, hypovolemia

Contraindication: Glaucoma, severe anemia

 

Nitroprusside

Niprid, Nitropress

Onset: Rapid

Mode of action: peripheral vasodilator

Route

Dose

Frequency

Infusion 0.5-10 mcg/kg/min,

Usual dose is 3 mcg/kg/min

neonates max = 6 mcg/kg/min

 
Side effects: Profound hypotension, metabolic acidosis, weakness, psychosis, headache, increased ICP, thyroid suppression, nausea, sweating, cyanide and thiocyanate toxicity

Caution: Monitor thiocyanate level, if used >48 hr. Keep level < 35 mg/L.

Contraindication: Reduced cerebral perfusion, coarctation of the aorta, AV shunts

 

Prazosin HCl

Minipress

Onset: 1-3 hr

Mode of action: vasodilator, a adrenergic receptor blocker

Route

Dose

Frequency

PO Initially: 5 mcg/kg as test dose, then titrate to 25 mcg/kg

max: 4 mg/dose

QID
Side effects: Orthostatic hypotension, syncope, tachycardia, dizziness, headache, fluid retention, nausea, dry mouth, nasal congestion, urinary frequency

Caution: "First dose phenomenon": orthostasis, syncope, usually within 90 min of first dose

 

Diuretic Agents 

Bumetanide

Bumex

Onset: PO: 30-60 min, IV: 5-10 min

Mode of action: Loop diuretic, prevent re-absorption of chloride at ascending loop of Henle

Route

Dose

Frequency

IV, IM, PO 0.015-0.1 mg/kg,

max = 2 mg

QD
Infusion 0.01-0.025 mg/kg/hr  
Side effects: Hypotension, dizziness, weakness, vertigo, nausea, muscle cramps, hypoglycemia, increase serum creatinine, hyperurecemia, hypokalemia, hypocalcemia, hyponatremia, hypochloremia, hypercalciurea. Metabolic alkalosis.

Caution: Sulfonamide hypersensitivity due to cross reaction.

 

Chlorothiazide

Diuril

Onset: 1-2 hours

Mode of action: Inhibits renal tubular re-absorption

Route

Dose

Frequency

PO 10-20 mg/kg BID
IV 1-4 mg/kg BID
Side effects: Hypokalemia, hypochloremia, alkalosis, hypotension, dizziness, vertigo, hyperlipidemia, cholestasis, muscle weakness, parasthesia, pre-renal azotemia,

hyperurecemia, hyperglycemia, blood dyscrasias, allergic reaction

Caution: Sulfonamide hypersensitivity

 

Ethacrynic Acid

Edecrin

Onset: PO: 10-30 min, IV: rapid

Mode of action: Potent loop diuretic, prevent re-absorption of chloride at ascending loop of Henle

Route

Dose

Frequency

PO 1-3 mg/kg,

max =25 mg

BID
IV 1 mg/kg BID, TID
Side effects: Hypovolemia, hypokalemia, hypochloremic alkalosis, pre-renal azotemia, hyperurecemia, 8th cranial nerve damage (deafness), abnormal LFTs, agranulocytosis or thrombocytopenia, anorexia, dysphagia, GI bleeding, GI irritation, rash, hypotension, vertigo, hyponatremia, hyperglycemia, hepatotoxicity, ototoxic, tinnitus, hematuria, hypomagnesemia

Drug interactions: Potentiate potassium wasting with other loop diuretics. Increase risk for ototoxicity when used with aminoglycosides. Increase effect of Warfarin because it displaces warfarin from protein binding

Caution: Renal dysfunction

 

Furosemide

Lasix

Onset: 5-15 min

Mode of action: Loop diuretic, prevent re-absorption of chloride at ascending loop of Henle

Route

Dose

Frequency

PO 2-4 mg/kg QD - QID
IV 1-2 mg/kg

max = 80 mg

Q6H, PRN
Infusion 0.1-1 mg/kg/hr  
Side effects: Hypovolemia, hypokalemia, hypochloremia,

hypocalcemia, hypochloremic metabolic alkalosis. Hyperuricemia. Dermatitis,

hyperglycemia, azotemia, anemia, ototoxicity especially when used with aminoglycocides, hypotension, dizziness, vertigo, headache, photosensitivity, agranulocytosis, ototoxicity, hepatitis, anorexia, pancreatitis, interstitial nephritis, hypercalciurea

Drug interactions: Increase risk of ototoxicity when used with other ototoxic drugs, e.g. aminoglycoside

Caution: Prolonged use in neonates causes nephrocalcinosis.

Renal or hepatic failure

 

Hydrochlorothiazide

Hydrodiuril

Onset: 1-2 hr

Mode of action: Inhibits sodium re-absorption in the distal renal tubule

Route

Dose

Frequency

PO 1-2 mg/kg

max =100 mg

BID
Side effects: Drowsiness, vertigo, headache, hypokalemia, hyperlipidemia, hypochloremic metabolic alkalosis, nausea, muscle cramps, pancreatitis, agranulocytosis, hemolytic anemia, hepatitis, parasthesia, pre-renal azotemia, hyperuricemia, hyperglycemia, blood changes, allergic reaction

Caution: Sulfonamide cross sensitivity

 

Metolazone

Zaroxolyn

Onset: 1 hour

Mode of action: Blocks sodium re-absorption at distal renal tubules

Route

Dose

Frequency

PO 0.1-0.2 mg/kg

max = 5 mg

BID
Side effects: Hepatic dysfunction, calcium retention, GI upset, orthostatic hypotension, , hypokalemia, hypochloremic metabolic alkalosis, hyperglycemia, hypomagnesemia, hyperuricemia, tinnitus

Drug interactions: Increase hypokalemia with other potassium wasting drugs, e.g. furosemide

Caution: Hepatic disease, oral absorption varies between products, sulfonamide cross sensitivity

 

Spironolactone

Aldactone

Onset: Hours

Mode of action: Aldosterone blocker, therefore decrease potassium loss

Route

Dose

Frequency

PO 0.5-1.5 mg/kg

max = 50 mg

BID, TID
Side effects: Potassium retention, GI irritation rash, gynecomastia, hyperchloremia metabolic acidosis, amenorrhea, anorexia, agranulocytosis, hyponatremia

Contraindications: Renal failure

Caution: May potentiate ganglionic blocking agents and antihypertensives

Drug interactions: Hyperkalemia when used with other potassium sparing drugs. May decrease clearance of digoxin, may decrease hypoprothrombinemia effect of anticoagulants

 

Drugs used in cardiac emergencies 

Atropine
Onset: Rapid

Mode of action: Blocks acetylcholine activity

Route

Dose

Frequency

IV, ET 0.01-0.02 mg/kg,

min = 0.1 mg

max = 1 mg

PRN
Side effects: Dry mouth, blurred vision, tachycardia, dry hot skin, restlessness, fatigue, difficult micturition, impaired GI motility, CNS symptoms, hyperthermia, palpitation, delirium, headache, tremor

Contraindication: Glaucoma, tachycardia, thyrotoxicosis, GI obstruction, uropathy

 

Diphenhydramine

Benadryl

Onset: PO: 20-40 min, IV: 10-20 min

Mode of action: Histamine 1 receptor antagonist

Route

Dose

Frequency

PO, IV, IM 1-2 mg/kg

max = 50 mg

QID
Side effects: Sedation, drowsiness, insomnia, vomiting, anorexia, constipation, diarrhea, anticholinergic effect, hypotension, palpitation, tachycardia, paradoxical excitement, fatigue, photosensitivity, rash, dry mouth, urinary retention, blurred vision, thickened bronchial secretions

Caution: Peptic ulcers, hyperthyroidism

Contraindication: Angle closure glaucoma, GI or urinary tract obstruction

 

Bretylium Tosylate

Bretylol

Onset: Rapid

Mode of action: Sodium channel blocker, inhibits post-ganglionic norepinephrine release

Route

Dose

Frequency

IV 1st dose: 5 mg/kg

repeat doses: 10 mg/kg

Total dose = 30 mg

Q10-20 min
Side effects: Hypertension followed by hypotension, PVC, arrhythmias, increased sensitivity to digitalis and catecholamines, nausea, vomiting, hyperthermia, nasal congestion, conjunctivitis, diaphoresis,

Caution: Renal dysfunction, severe hypotension,

Contraindication: Digitalis induced arrhythmias

 

Calcium Chloride
Onset: rapid

Mode of action: Enhances contractility through regulation of action potential

Route

Dose

Frequency

IV Cardiac arrest: 20 mg

max = 500 mg (5 ml)

Q10 min PRN
Side effects: Bradycardia, hypotension, peripheral vasodilation, hypercalcemia, hypomagnesemia, hyperchloremic acidosis, hypercalcemia

Caution: Central venous line recommended. Max. conc. is 20 mg/ml infusion Extravasation may lead to tissue necrosis, use local hyaluronidase if occur, may precipitate arrhythmia in digitalised patient.

Contraindication: Hypercalcemia, ventricular fibrillation

 

Epinephrine Hydrochloride

1:10,000

Adrenaline

Onset: Rapid

Mode of action: Stimulates alpha, beta 1 and 2 adrenergic receptors

Route

Dose

Frequency

IV, ET 0.01 mg/kg

max = 1 mg

PRN
Side effects: Anxiety, tremor, headache, tachycardia, hypertension, arrhythmias

 

Lidocaine

Xylocaine

Onset: Rapid

Mode of action: Class Ib antiarrhythmic agent, sodium channel blocker , local anesthetic depressing myocardial irritability

Route

Dose

Frequency

IV. ET 0.5-1.0 mg/kg Q 5 min, PRN
Infusion 20-50 mcg/kg/min  
Side effects: Hypotension, shock, nausea, seizures, respiratory depression, anxiety, euphoria, drowsiness, agitation

Caution: Hepatic disease, heart failure

Contraindication: AV block

Therapeutic level: 2-5 mcg/ml

 

Sodium Bicarbonate
Onset: IV rapid

Mode of action: Alkalization

Route

Dose

Frequency

IV, ET Cardiac arrest: 0.5-1 mEq/kg  
Side effects: Increased oxygen affinity to Hgb, alkalosis, edema, hyperosmolality, hypernatremia cerebral hemorrhage, hypokalemia, hypocalcemia,

Caution: In infants under 3 mo., use conc. of 0.5 mEq/ml. Do not mix with calcium salts or catecholamines. Extravasation may cause tissue necrosis, infiltrate with hyalurunidase to minimize tissue necrosis

Contraindication: Inadequate alveolar ventilation

 

Pancuronium

Pavulon

Onset: Rapid

Mode of action: Post-synaptic acetylcholine receptor blocker

Route

Dose

Frequency

IV 0.1 mg/kg PRN
Side effects: Tachycardia

Caution: Secure airway prior to administration. Effect increased by hypothermia, acidosis, decreased renal function, volatile anesthetics, succinycholine, hypokalemia, and aminoglycoside

 

Vecuronium bromide

Norcuron

Onset: Rapid

Mode of action: Post-synaptic acetylcholine receptor blocker

Route

Dose

Frequency

IV 0.1 mg/kg PRN
Caution: Hepatic impairment, neuromuscular disease. Longer recovery period in infant less than one year. Potency and duration of effect may be prolonged by volatile anesthetics, aminoglycoside, metronidazole, tetracycline, bacitracin, and clindamycin.

Antidotes: Neostigmine, pyridostigmine, or edrophonium.

 

Sedatives 

Chloral Hydrate

Noctec

Onset: 10-20 min..

Mode of action: CNS depressant

Route

Dose

Frequency

PO, PR 20-100 mg/kg

max = 2000 mg

Q6-8 hr PRN
Side effects: Irritates mucosa causing upset GI, laryngospasm if aspirated.

Myocardial and respiratory depressant. CNS depression

Contraindications: Hepatic or renal impairment

Caution: Heart disease

 

Chlorpromazine

Thorazine

Onset: Rapid

Mode of action: Tranquilization, central dopaminergic antagonist and a blocker

Route

Dose

Frequency

IM, IV, PO 0.5-2 mg/kg

max = 50 mg

Q 4-6 hr PRN
Side effects: Alpha blocking, hypotension, jaundice, lower seizure threshold, extrapyramidal symptoms, agranulocytosis, leukopenia, hepatotoxicity.

Contraindications: Narrow angle glaucoma, severe liver and cardiac disease

Caution: Patients with cardiac disease, seizure disorder

ECG changes: prolonged PR, flattened T, ST depression

 

Diazepam

Valium

Onset: Rapid

Mode of action: CNS depression through enhanced GABA at the limbic system

Route

Dose

Frequency

IM, IV 0.04- 0.25 mg/kg PRN
PO 0.04-0.25 mg/kg Q8 Q 8 hr, PRN
Side effects: Hypotension, CNS and respiratory depression, physical dependence

Contraindications: Narrow angle glaucoma

Caution: Glaucoma, shock, depression, hypoalbuminemia, hepatic dysfunction. No faster than 1-2 mg/min(IV)

 

Fentanyl

Sublimaze

Onset: Rapid

Mode of action: Semisynthetic opiate analgesic

Route

Dose

Frequency

IV, IM 1-3 mcg/kg Q2 hr, PRN
Infusion 1-5 mcg/kg/hr  
Side effects: Respiratory depression (beyond period of analgesia). Chest wall rigidity with large bolus doses. Bradycardia, functional ileus., physical dependence

Contraindications: Increase ICP and IOP

Caution: IV dose over 3-5 min, hepatic and renal insufficiency, respiratory disease

 

Ketamine

Ketalar

Onset: Rapid

Mode of action: Dissociative anesthesia by direct action on the cortex and limbic system

Route

Dose

Frequency

IV 0.5-2 mg/kg Q 2 hr PRN
PO 6-10 mg/kg Q 2 hr PRN
IM 3-7 mg/kg Q 2 hr PRN
Infusion 0.5-2 mg/kg/hr Q 2 hr PRN
Side effects: Hypertension, tachycardia, respiratory depression, laryngospasm, hypersalivation, delirium. CNS symptoms (dream like state, confusion, agitation)

Contraindications: Elevated ICP, thyrotoxicosis, CHF, angina and psychosis

disorder.

Caution: Must be used in conjunction with antisialagouge due to increase secretions

 

Meperidine

Demerol

Onset: Rapid

Mode of action: Semi-synthetic opiate analgesic

Route

Dose

Frequency

IM, IV, SC, PO 1-2 mg/kg

max = 100 mg

Q 3-4 hr PRN
Side effects: Nausea, vomiting, respiratory depression, smooth muscle spasm, physical dependence, seizures

constipation and lethargy. Tachycardia.

Contraindications: Cardiac arrhythmia, asthma, increased ICP, renal failure

Caution: potentiated by MAO inhibitors, phenothiazines and

other CNS depressants, biliary colic.

 

Midazolam

Versed

Onset: IV: Rapid, IM: 5-15 min, PO/PR: 15-30 min

Mode of action: CNS depression by inducing GABA at limbic system

Route

Dose

Frequency

IV 0.05-0.1 mg/kg

max-2.5 mg

PRN
IN 0.2 mg/kg PRN
PO 0.3-0.75 mg/kg PRN
IM 0.1-0.2 mg/kg PRN
PR 0.5-1.0 mg/kg PRN
Infusion 0.05-0.5 mg/kg/hr  
Side effects: Respiratory depression, hypotension, bradycardia, myclonic jerking in neonates

Contraindications: Narrow angle glaucoma, shock, physical dependence.

Caution: Lower dose by 25% when used with narcotics, cimetidine or anesthetic agents. Care should be observed in the post-operative open-heart patient, and with hemodynamic instability.

 

Morphine sulfate

Duramorph, Centin, Astramorph

Onset: IV: Rapid, PO: 15-30 min

Mode of action: Strongest narcotic analgesic. Unspecified aid with CHF, pulmonary edema and anoxic spells

Route

Dose

Frequency

IV, IM, SC 0.05-0.2 mg/kg

max = 10 mg/dose

Q2-4 hr, PRN
Infusion 0.01-0.1 mg/kg/hr  
Side effects:

Physical dependence, CNS and respiratory depression, bronchospam, nausea, vomiting,

constipation, hypotension, bradycardia, increases ICP, meiosis, biliary or urinary

spasm

Contraindications: Increase ICP and IOP (unless ventilated), shock.

Caution: Hepatic failure, renal failure

 

Naloxone

Narcan

Sedative reversal agent

Onset: Rapid

Mode of action: Opioid antagonist

Route

Dose

Frequency

IV, IM, SC, ET 0.01-0.1 mg/kg, max = 2 mg Q 3 min PRN
Infusion Last effective dose over one hr, then decrease by 50% every hr for 6-12 hr  
Side effects: Narcotic withdrawal symptoms in opioid dependence, with abrupt reversal of narcotic may cause nausea, vomiting, diaphoresis, tachycardia, hypertension, and tremulousness

Caution: Chronic cardiac disease.

 

Promethazine

Phenergan

Onset: Rapid

Mode of action: Antihistaminic, anti-emetic, phenothiazine

Route

Dose

Frequency

IV, IM, PR 0.5-1.0 mg/kg

max = 50 mg

Q 4-6 hr PRN
Side effects: CNS depression, anticholinergic effect, antihistaminic effect, photosensitivity, extrapyramidal reaction

Contraindications: Increase IOP

Caution: Seizure, liver disease, CV disease

 

Miscellaneous 

Acetylsalicylic Acid

Aspirin

Mode of action: Inhibits prostaglandin synthesis which prevents thromboxane A2 formation, leading to decrease platelet aggregation.

Route

Dose

Frequency

PO Antiplatelet:

3-10 mg/kg

QD
  Anti-inflammatory:

15-25 mg/kg

QD
Side effects: Rash, nausea, hepatotoxicity, GI bleeding, bronchospasm, GI distress, tinnitus

Caution: Renal dysfunction, erosive gastritis, peptic ulcer or gout

Contraindication: Hepatic failure, bleeding disorder, hypersensitivity to other NSAID, children <16 yr with chicken pox or flu symptoms, due to the association with Reye's syndrome

 

Ammonium Chloride
Mode of action: Chloride supplementation in severe hypochloremic metabolic alkalosis, as seen with loop diuretics

Route

Dose

Frequency

PO, IV 12.5-25 mg/kg

Or

(0.2)(wt in kg)(103-Cl level)(0.5) = mEq needed

Q 6-8 hr PRN
Side effects: Bradycardia, phlebitis and necrosis with infiltration, headache, hyperammonemia, GI irritation, hyperventilation.

Caution: Max conc for infusion: 0.2 mEq/kg/hr peripheral and 0.4 mEq/ml central; max rate of infusion 1 mEq/kg/hr (53 mg of NH4Cl = 1 mEq of Cl)

Contraindication: Severe hepatic or renal dysfunction

 

Argeninine HCl (10%)

R-Gene

Mode of action: Chloride supplementation in severe hypochloremic metabolic alkalosis, as seen with loop diuretics

Route

Dose

Frequency

PO, IV (0.4)(wt. in kg)(103-Cl level)(0.5) = ml needed Q6 hr PRN
Side effects: Flushing and headache with rapid infusion, hyperglycemia, hyperkalemia, GI upset, phlebitis, necrosis with infiltration.

Caution: Max rate of infusion one gm/kg/hr

Contraindication: Renal or hepatic failure

 

Dexamethasone

Decadron

Mode of action: Anti-inflammatory effect by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability

Route

Dose

Frequency

PO, IV Airway edema:

0.1-0.5 mg/kg

QID X 4 before extubation
  Anti-inflammatory:

0.02-0.07 mg/kg

QID
Side effects: Hypertension, headache, vertigo, psychosis, heart failure, adrenal suppression, hyperglycemia, hypokalemia, Cushing's syndrome, gastric ulceration, muscle weakness, osteoporosis, fractures, cataract, glaucoma

Caution: Active infections, hypertension, CHF, liver failure, hypothyroidism, thromboembolic disease

 

Heparin
Onset: IV rapid

Mode of action: Potentiates antithrombin III which inactivates thrombin and prevents the conversion of fibrinogen to fibrin

Route

Dose

Frequency

IV 50-100 U/kg, max = 5,000-10,000 U Q4hr
Infusion Maintenance:

10-25 U/kg/hr, adjust according to PTT

max = 800-1,600 U/hr

 
Side effects: Bleeding, allergy, alopecia, thrombocytopenia, fever, headache, chills, urticaria, increased LFTs

Caution: Adjust dose to desired clotting time. Use preservative free heparin in neonates.

Antidote: Protamine sulfate.

Contraindication: Severe thrombocytopenia, suspected intracranial hemorrhage.

Drug interactions: Increase susceptibility to bleeding with other anticoagulants.

 

Ibuprofen

Advil, Motrin

Mode of action: Non-steroidal anti-inflammatory agent (inhibits PG synthesis)

Route

Dose

Frequency

PO Analgesic & anti-pyretic:

4-10 mg/kg

Q 6-8 hr
Anti-inflammatory:

10-15 mg/kg

Q 6-8 hr
Side effects: Drowsiness, fatigue, headache, GI irritation, inhibition of platelet aggregation, hepatitis, acute renal dysfunction, blood dyscrasias.

Caution: CHF, renal disease, hepatic disease

Drug interaction: may increase digoxin, methotrexate lithium serum levels. May decrease effect of furosemide & bumetanide.

Contraindication: Active GI bleeding, GI ulcers, platelet dysfunction

 

Indomethacin

Indocin

Onset:

Mode of action: Prostaglandin synthesis inhibitor

Route

Dose

Frequency

IV Closure of ductus arteriosus:

0.1-0.25 mg/kg

Q12-24 hr

For PDA closure: 3 dose course may be used.

Side effects: Decrease platelet aggregation, GI disease: ulcers, diarrhea, blood dyscrasias, GI bleeding, hypertension, oligurea, renal failure, somnolence, hyperkalemia, hypoglycemia, hepatitis, tinnitus

Caution: Monitor renal and hepatic function. Keep urine output >0.6 ml/kg/hr

Contraindication: Neonates with BUN >30 mg/dl, Cr >1.8 mg/dl., thrombocytopenia, recent IVH, NEC, or active bleeding

 

Isoproterenol

Isuprel

Onset: 30-60 sec

Mode of action:

Chronotropy: beta adrenergic receptor stimulation

Route

Dose

Frequency

IV infusion 0.025-2 mcg/kg/min  
Side effects: Tachyarrhythmias, hypertension, myocardial ischemia, hypotension, dizziness, headache, vertigo, nausea, tremor, sweating

Caution:. Do not use discolored solution

Contraindication: Angina, ventricular arrhythmia, narrow-angle glaucoma, digitalis intoxication, IHSS

 

Prostaglandin E1

Prostin

Onset: 1.5-3 hr

Mode of action: Direct effect on vascular smooth muscles causing pulmonary, systemic and ductus arteriosus vasodilation

Route

Dose

Frequency

Infusion Initial:

0.05-0.1 mcg/kg/min

Maintenance:

0.01-0.04 mcg/kg/min

 
Side effects: Hypotension, flushing, tachycardia, fever, seizure like activity, apnea, hypocalcemia, diarrhea, hypoglycemia, inhibition of platelet aggregation, cortical hyperostosis (chronic therapy)

Caution: Apnea occur in 10-12 % of neonates, usually appear in first hour of therapy

 

Protamine sulfate
Onset: 5 min

Mode of action: Forms a stable salt with Heparin, thus neutralizing it's effect

Route

Dose

Frequency

IV 1 mg for each 90-100 units heparin

max dose = 50 mg

PRN
Side effects: Hypotension, bradycardia, flushing, pulmonary hypertension, nausea, dyspnea

Caution: Known allergic reaction to fish or previous exposure to protamine.

Max. infusion rate: 5 mg/min

 

Streptokinase

Streptase, Kabikinase

Onset: Rapid

Mode of action: Converts plasminogen to plasmin, thus promoting thrombolysis

Route

Dose

Frequency

IV Initial:

3500-4000 units/kg over 30 min

Maintenance:

1000-1500 unit/kg/hr

 
Side effects: Hypotension, arrhythmia, flushing, fever, urticaria, bleeding, bronchospasm

Caution: Avoid IM injection

Contraindication: Major surgery within 10 days, GI bleeding, recent trauma, severe hypertension, internal bleeding, CVA (within 2 months), intra-cranial or intra-spinal surgery, brain carcinoma

 

Tolazoline HCl

Priscoline

Onset: minutes, peak effect 30 min

Mode of action: Alpha adrenergic receptor antagonist, peripheral vasodilation is mediated by histamine like action

Route

Dose

Frequency

IV Test dose:

1-2 mg/kg

Over 10 min
Infusion Neonates: 0.5-1 mg/kg/hr

Children: 1-2 mg kg hr

 
Side effects: Hypotension, flushing, tachycardia, hypochloremic metabolic alkalosis, increased secretions, nausea, diarrhea, gastric bleeding, thrombocytopenia, agranulocytosis, mydriasis, oligurea, pulmonary hemorrhage.

 

Urokinase

Abbokinase

Onset: Rapid

Mode of action: Direct activation of plasminogen to plasmin, thus causing thrombolysis

Route

Dose

Frequency

IV Occluded IV catheter:

5,000 U/ml conc. Instill a volume equal to that of the catheter in each lumen and leave for 1-4 hr, then aspirate catheter, DO NOT flush.

PRN
Infusion DVT, pulmonary emboli:

4,400 U/kg over 10 min, then 4,400 U/kg/hr for 12-72 hr

 
Side effects: Allergic reaction, fever, rash, bronchospasm, bleeding.

Caution: Avoid IM injection

Contraindication: Bleeding, AV malformation, history of CVA or recent trauma, brain carcinoma, intra-cranial or intra-spinal surgery

 

Vitamin K (phytonadione)

Aqua Mephyton, Mephyton

Onset: PO 6-12 hr. IV 1-2 hr

Mode of action: Cofactor in the synthesis of the clotting factors II, VII, IX and X

Route

Dose

Frequency

PO

IV, IM

2.5-5 mg/day

1-2 mg/dose

QD
Side effects: Flushing, hypotension, dizziness, GI upset, changes in taste, sweating, anaphylactoid-like reaction with IV administration

Caution: IV administration should be restricted for emergencies only, since risk of severe adverse reaction could occur. Do not use in patients with prosthetic valves.

 

Warfarin

Coumadin, Sofarin

Onset: 36-72 hr

Mode of action: Inhibits hepatic synthesis of vitamin K-dependent factors (I, VII, IX, X)

Route

Dose

Frequency

PO Loading:

0.2 mg/kg, max = 15 mg

QD
  Maintenance:

0.05-0.35 mg/kg, max = 10 mg

QD
Side effects: Fever, skin lesions, anorexia, hemorrhage, hemoptysis

Caution: Adjust to desired PT, INR, fever, skin lesions with necrosis, anorexia, hemorrhage, hemoptysis . Give 0.1 mg/kg loading dose with impaired liver function.

Drug interactions: Warfarin effect increases with ethacrynic acid, indomethacin, mefenamic acid, phenylbutazone, aspirin,

Antidote: Vitamin K

Contraindication: Bleeding, liver or renal failure, malignant hypertension

 

 


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