COMMON MEDS FOR COMMON COMPLAINTS, AND VALUABLE TIPS TO KEEP INTERN YEAR GOING SMOOTHLY

Transcription

1 COMMON MEDS FOR COMMON COMPLAINTS, AND VALUABLE TIPS TO KEEP INTERN YEAR GOING SMOOTHLY 32

2 COMMON MEDS and DOSES Note: most of these dosings are for standard adults, pediatric dosing is pretty much all weight based and you also have to adjust for example in adults with renal or hepatic dysfunction use this only as a general guide, consult your upper level or friendly floor pharmacist for additional specifics on dosing for your patients PAIN CONTROL Equianalgesic Table Oral (PO)/Rectal (PR) Dose (mg) Analgesic Parenteral Dose SC, IM, IV (mg) Duration of action 30 Morphine hours 20 Oxycodone hours (Oxycontin) 7.5 Hydromorphone hours (Dilaudid) --- Fentanyl Hydrocodone hours 20 Methadone hours 200 Codeine Meperidine hours Morphine metabolites can remain in patients with renal failure, both morphine and dilaudid metabolized in liver but morphine has active metabolite Common PO combinations: Percocet (Oxycodone/Acetaminophen 2.5/5/7.5/10/15mg 325mg) - Liquid Roxicet - Schedule II need attending info on prescription Lortab/Norco (Hydrocodone/Acetaminophen 2.5/5/7.5/10/15mg 325mg) - Liquid Lortab elixir Vicodin (Hydrocodone/Acetaminophen) 33

3 - Watch b/c some formulations come with 500mg tylenol and can quickly reach max daily dose ot tylenol ***Current recommendations at Emory now to not exceed 3 grams of tylenol per day so can don t write orders/prescriptions for (2) 5-325mg percocets q4hrs this would exceed that dosing Tramadol (Ultram) - Can start at 25-50mg q8hr; max dose 100mg q6hr - Can schedule Transdermal Fentanyl Patch - Not recommended for acute pain or pain after an operation - Onset/offset of action is ~12-24 hours; peak effect seen in ~24-48hrs - Do not cut patches Transdermal Fentanyl (mcg/hr) Oral Morphine Total Daily Dose TDD (mg/day) IV Morphine TDD (mg/day Non-opioid Alternatives Topical Lidocaine (Lidoderm) patches - on for 12 hrs per day, removed for 12 hrs - expensive, also available in ointment that is cheaper for d/c Ketoralac (Toradol) mg IV q6-8hrs, often schedule if normal renal function - Avoid in older pts and any pts with any renal insufficency, can also increase bleeding risk, avoid in trauma - Used extensively in children NSAIDS avoid in renal insufficiency, may also inc risk of bleeding - Ibuprofen, etc 34

4 Patient Controlled Analgesia PCAs Typically either Morphine or Dilaudid (Morphine only at Grady) Common Settings Morphine Hydromorphone Standard 1 mg/ml 0.2 mg/ml concentrations PCA bolus dose 1 mg 0.2 mg Lockout time 6-10 min 6 min Usual 1-hr Max Dose 10-12mg 2mg Remember that you can give bolus off of PCA if pain too great (usually 2-3mL) Local Injectable Anesthetics Name Onset (min) Maxiumum dose Max Dose w/ epi Duration of Action (min) Lidocaine <2 3mg/kg 5mg/kg (longer w/epi) Bupivacaine mg/kg 3mg/kg 200+(up to 540 w/epi) Mepivacaine mg/kg 5mg/kg Ropivacaine mg/kg 3mg/kg

5 With every pain control, you must have an equally important BOWEL REGIMENS Ducosate (Colace) Pretty much everyone gets this 100mg qday or BID if on any narcotic pain medication, relatively gentle stool softener Polyethylene Glycol (Miralax) - 17gm daily - A bulking, osmotic agent Bisacodyl (Dulcolax) mg PO daily OR 10mg PR daily (MAX = 30mg PO when complete evacuation is needed) - As a PR medication, it will stimulate a BM if stool present Sennosides (Senna) - Stimulant laxative Other high osmotic agents can also have a cathartic effect so be aware: - CT oral contrast - Golytely, of course - Kayexalate - Lactulose 36

6 NAUSEA/VOMITING Pain meds and anesthesia around surgery are also very good at causes nausea and vomiting, especially PO meds without food Odansteron (Zofran) - 4mg/8mg IV q4-8hrs PRN - PO ODT (oral-dissolving tab) can be given for occasional nausea at home - PO - Watch for prolonged QT - Is also fairly expensive and not covered by all insurances Promethazine (Phenergan) mg PO/IM/IV/PR q4-6 hr PRN - Can make some people a little loopy - People tend to like the IV form because of the high associated and it is not always available at each hospital Prochlorperazine (Compazine) mg PO/IM/IV/PR q4-6hr PRN Metoclopramide (Reglan) - Used for gastroparesis, decreased peristalsis mg PO/IV/IM up to 4 times a day PRN (20mg doses may be used) Scopolamine patch Diphenhydramine (Benedryl) can also have some beneficial anti-nausea effects ITCHING Diphenhydramine (Benedryl) mg PO/IV q6hr PRN - NTE 400 mg/day - Can also have some anti-nausea effects - Is sedating write as a scheduled PRN with caution in elderly Hydroxine (Atarax) mg PO/IM q6hr or q8hr PRN 37

7 SLEEP A favorite call particularly when you re on cross-cover at night Benedryl - IV/PO - Be weary in older patients anti-cholinergic effects can worsen dementia and sun-downing Ambien mg PO qhs - Can cause nightmares, see if someone has taken before - In general, do not start unless they were on it at home Melatonin Trazadone AGITATION You have to be very careful with these medications and ensure that your patient doesn t have another reason like hypoxia or sepsis causing the agitated state Benzodiazepines (Ativan, Versed, Xanax) Need to consider pt age, renal/hepatic dysfunction, etc, avoid if possible Antipsychotics: Haloperidol (Haldol)/Quetapine (Seroquel) ALWAYS get an EKG first to ensure you won t prolong their QT into an arrhythmia if you give it to them 38

8 HYPERTENSION Hydralazine - PO/IV - Most often 10mg IV q6hr PRN, can go up to 20mg - Can cause reflex tachycardia, often held for HR>100 Labetalol - Less selective beta-blocker - PO/IV formulations - Quick onset/off with IV - 5mg IV q5-10min until effect Metoprolol - Selective beta-blocker - PO/IV - 5mg IV q4-6hr - Not very good for BP control but relatively safe and good for HR Esmolol drip - likely only in ICU, for hypertensive emergency, aortic dissection Clonidine - If someone is on this at home, rebound hypertension common if you stop it - PO or Transdermal patch - PO clonidine works relatively fast, can be helpful at Grady Calcium channel blockers not typically first line agents but some patients are on these at home and can be very hypertensive until restarted - Amlodipine - Nifidepine (Procardia) Typical avoid ACE inhibitors, ARBs in hospital, typically see Cr bump with restarting them 39

9 COMMON IV TO PO CONVERSIONS Medication Bioavailability IV:PO Comments Ratio Acyclovir 10 30% NA See IV/PO dosing for with dose indication (not 1:1) Azithromycin 34 52% 1:1 IV and PO dosing mg QD Bactrim % 1:1 5mL (1 vial) = 1 SS Tab; 2 vials = DS tab Bumetanide 85-95% (72% 1 study) 1:1 1mg IV = 1mg PO (max oral = 10mg/day) Clindamycin 90% 1:1 MAX oral dose is 450 q6h Cyclosporine 10 89% (mean 30%) Varies IV Dose essentially 33% of PO dose Digoxin 60 80% NA Decrease IV dose by 20-25% from PO Famotidine 20 66% 1:1 20mg IV = 20mg PO Fluconazole 90% 1:1 200mg IV = 200mg PO Furosemide 60 70% 1:2 40mg IV = 80mg PO (variable) Ganciclovir 5% NA PO Maintenance 1000mg TID IV Treatment 5mg/kg q12 IV Maintenance 5mg/kg QD ***See Renal Dosing*** Haloperidol 60% 1:2 24mg PO = 15mg IV Hydromorphone 62% NA 1.5-2mg IM/SC = 6-7mg PO 8-10mg IV = 40mg PO Labetolol 25 40% NA Once BP Controlled with IV therapy, switch to PO therapy at 200mg, then mg 6-12 hours later titrating to effect Levofloxacin 99% 1:1 500mg IV = 500mg PO Levothyroxine 48 80% 1:2 Initial IV dose is ½ PO Linezolid 100% 1:1 600mg IV = 600mg PO 40

10 Lorazepam 100% 1:1 1mg IV = 1mg PO Metoclopramide 50 80% 1:1 Essentially a 1:1 conversion; 10mg IV =10mg PO Metoprolol 50% 1:2.5 10mg IV q6h = 50mg PO BID Metronidazole 100% 1:1 500mg IV = 500mg PO Morphine 20 40% 1:3-4 10mg IM/SC = 30-40mg PO 4mg IV = 12-16mg PO Phenytoin Variable 1:1 100mg IV = 100mg PO Rifampin 90 95% 1:1 600mg/day Tacrolimus 14 32% 1:3-4 Oral Dose is 3-4 times IV dose IV infusion: mg/kg/day PO dose: mg/kg/day BID Valproic Acid 90% 1:1 Brand Name Depacon Remember if you re in a bind and a patient is NPO and has no IV, there are many IV pain and sedation medications that can be given IM if needed until a line is available CONVERSION NOTES: 41

11 VALUABLE TIPS Nasogastric tube (NGT) maintenance - If an NG is not working, look at whether or not it is in the correct position. There are 4 black marks on the the NG, you want two inside of the patient s nose and two outside for the vast majority of patients - Remove the sump caps off NGTs if this becomes wet it becomes a plug and it doesn t add to the function of the NG other than being a potential hinderance to proper functioning o o o Have 60cc slip-tip syringe at pt bedside Flush sump (blue) tube with air and should here vacuum if open. Once the sump port gets wet, it will affect the ability of the port to provide the sump function Can also flush main port with water and watch for return and/or pull back to see if you meet resistance (should flow freely) Intravenous Fluids - For patients receiving IVF, it is important (with a few exceptions) to change the fluid type from resuscitative fluid to maintenance fluid - If a patient is NPO, they will need a fluid with a sugar source and K, provided they are not hyperkalemic (D5 1/2NS +20 meq K/L) - Common Rates of fluid and how much you are giving in 24 hours o 42 ml/hr 1L o 63 ml/hr 1.5L o 84 ml/hr 2L o 100 ml/hr = 2.5 L o 125 ml/hr = 3L Be sure to restart home meds when tolerating PO. Check with your upper level regarding anticoagulants/antiplatelet drugs and diuretics. IF IN DOUBT OF ANYTHING, CALL YOUR UPPER LEVEL (THIS CANNOT BE STRESSED ENOUGH) 42

12 NOTES: 43