Pocket Guide to Critical Care Pharmacotherapy

Pocket Guide to Critical Care Pharmacotherapy

John Papadopoulos Author David R. Schwartz Consulting Editor Pocket Guide to Critical Care Pharmacotherapy Second Edition

Author John Papadopoulos, B.S., Pharm.D., FCCM, BCNSP Department of Pharmacy New York University Langone Medical Center New York, NY, USA Consulting Editor David R. Schwartz, M.D. Pulmonary and Critical Care Division Department of Medicine New York University Langone Medical Center New York, NY, USA ISBN 978-1-4939-1852-2 ISBN 978-1-4939-1853-9 (ebook) DOI 10.1007/978-1-4939-1853-9 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014953966 Springer Science+Business Media New York 2008, 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

This handbook is dedicated to my wife, Maria, my children, Theodore Thomas, Eleni Thalia, and Pantelia Lia Zoe, and my mother, Eleni. I am grateful for your collective understanding of my professional commitment. John Papadopoulos

Preface Critical care medicine is a cutting-edge medical field that is highly evidence-based. Studies are continuously published that alter the approach to patient care. As a critical care clinician, I am aware of the tremendous commitment required to provide optimal evidence-based care. Pocket Guide to Critical Care Pharmacotherapy covers the most common ailments observed in critically ill adult patients. I utilize an algorithmic, easy-to-follow, systematic approach. Additionally, I provide references and web links for many disease states, for clinicians who want to review the available literature in greater detail. The contents of this handbook should be utilized as a guide and in addition to sound clinical judgment. Consult full prescribing information and take into consideration each drug s pharmacokinetic profile, contraindications, warnings, precautions, adverse reactions, potential drug interactions, and monitoring parameters before use. Every effort was made to ensure the accuracy of Pocket Guide to Critical Care Pharmacotherapy. The author, consulting editor, and publisher are not responsible for errors or omissions or for any consequences associated with the utilization of the contents of this handbook. New York, NY, USA John Papadopoulos, BS, PharmD, FCCM, BCNSP vii

Contents 1 Advance Cardiac Life Support... 1 2 Cardiovascular... 19 3 Cerebrovascular... 51 4 Critical Care... 59 5 Dermatology... 85 6 Endocrinology... 87 7 Gastrointestinal... 91 8 Hematology... 99 9 Infectious Diseases... 105 10 Neurology... 109 11 Nutrition... 113 12 Psychiatric Disorders... 119 13 Pulmonary... 125 14 Renal... 131 Index... 155 ix

List of Tables Table 1.1 ACLS pulseless arrest algorithm... 1 Table 1.2 Ventricular fibrillation/pulseless ventricular tachycardia algorithm... 2 Table 1.3 Pulseless electrical activity algorithm... 3 Table 1.4 Asystole algorithm... 3 Table 1.5 Bradycardia algorithm (slow [heart rate < 50/min] or relatively slow)... 4 Table 1.6 Tachycardia algorithm overview (heart rate > 100/min)... 4 Table 1.7 Management of stable atrial fibrillation/atrial flutter... 5 Table 1.8 Management of narrow complex stable supraventricular tachycardia (QRS < 0.12 s)... 7 Table 1.9 Management of stable ventricular tachycardia... 8 Table 1.10 Synchronized cardioversion algorithm for the management of symptomatic tachycardia... 9 Table 1.11 Common drugs utilized during ACLS... 11 Table 1.12 Pulseless electrical activity: causes (HATCH H 2 MO pph) and management... 16 Table 1.13 Pharmacological management of anaphylaxis/anaphylactoid reactions... 17 xi

xii List of Tables Table 2.1 Thrombolysis in myocardial infarction (TIMI) grade flows... 19 Table 2.2 TIMI risk score for STEMI... 19 Table 2.3 Acute pharmacological management of unstable angina and non-st elevation myocardial infarction with an initial invasive angiographic strategy... 20 Table 2.4 Acute pharmacological management of ST-elevation myocardial infarction (noninvasive or conservative strategy)... 25 Table 2.5 Considerations in patients with right ventricular infarctions... 34 Table 2.6 Contraindications to fibrinolytic therapy in patients with ST-elevation myocardial infarction... 34 Table 2.7 Management of acute decompensated heart failure... 35 Table 2.8 Vaughan Williams classification of antiarrhythmics... 37 Table 2.9 Antithrombotic pharmacotherapy for patients with new onset atrial fibrillation... 38 Table 2.10 Causes and management of acquired torsades de pointes... 39 Table 2.11 Hypertensive crises... 41 Table 2.12 Management of catecholamine/ vasopressin extravasation... 43 Table 2.13 Prevention of venous thromboembolism in the medical intensive care unit patient... 44 Table 2.14 Acute management of a deep-vein thrombosis or pulmonary embolism... 45 Table 2.15 Management of an elevated international normalized ratio (INR) in patients receiving warfarin pharmacotherapy... 48

List of Tables xiii Table 3.1 General supportive care for patients with an acute cerebrovascular accident... 51 Table 3.2 Blood pressure management in the setting of an acute cerebrovascular accident... 52 Table 3.3 Alteplase inclusion and exclusion criteria for cerebrovascular accident indication... 53 Table 3.4 Modified National Institute of Health Stroke Scale... 54 Table 3.5 Alteplase administration protocol for cerebrovascular accident indication... 56 Table 3.6 Management of an alteplase-induced intracranial hemorrhage... 57 Table 3.7 Management of intracranial hypertension (intracranial pressure 20 mmhg)... 57 Table 4.1 General drug utilization principles in intensive care... 59 Table 4.2 Management of severe sepsis and septic shock... 60 Table 4.3 Pain, agitation, and delirium guidelines... 63 Table 4.4 Riker sedation-agitation scale... 66 Table 4.5 Confusion assessment method for the diagnosis of delirium in intensive care unit patients... 66 Table 4.6 Neuromuscular blocker use in the intensive care unit... 68 Table 4.7 Reversal of nondepolarizing neuromuscular blockers... 69 Table 4.8 Factors that alter the effects of neuromuscular blockers... 70 Table 4.9 Management of malignant hyperthermia... 71 Table 4.10 Use of packed red blood cell transfusions in critically ill patients... 72

xiv List of Tables Table 4.11 Propylene glycol content of commonly utilized intravenous medications... 73 Table 4.12 Drug-induced fever... 74 Table 4.13 Pharmaceutical dosage forms that should not be crushed... 75 Table 4.14 Stress-related mucosal damage prophylaxis protocol... 75 Table 4.15 Therapeutic drug monitoring... 77 Table 4.16 Select antidotes for toxicological emergencies... 79 Table 5.1 Drug-induced dermatological reactions... 85 Table 6.1 Management of diabetic ketoacidosis and hyperosmolar hyperglycemic state... 87 Table 6.2 Management of thyrotoxic crisis and myxedema coma... 89 Table 7.1 Management of acute non-variceal Table 7.2 upper gastrointestinal bleeding... 91 Causes of diarrhea in the intensive care unit patient... 92 Table 7.3 Managing the complications of cirrhosis... 93 Table 7.4 Drug-induced hepatotoxicity... 97 Table 7.5 Drug-induced pancreatitis... 97 Table 8.1 Drug-induced hematological disorders... 99 Table 8.2 Management of heparin-induced thrombocytopenia... 100 Table 8.3 Management of methemoglobinemia... 102 Table 9.1 Common causes of fever in intensive care unit patients... 105 Table 9.2 Prevention of hospital-acquired and ventilator-associated pneumonia... 105 Table 9.3 Management of hospital-acquired and ventilator-associated pneumonia... 106 Table 9.4 Clinical pulmonary infection score (CPIS) calculation... 108

List of Tables xv Table 10.1 Management of convulsive status epilepticus... 109 Table 10.2 Medications that may exacerbate weakness in myasthenia gravis... 112 Table 11.1 Nutrition assessment... 113 Table 11.2 Principles of parenteral nutrition... 116 Table 11.3 Select drug nutrient interactions... 117 Table 11.4 Strategies to minimize aspiration of gastric contents during enteral nutrition... 118 Table 12.1 Management of alcohol withdrawal... 119 Table 12.2 Management of serotonin syndrome... 121 Table 12.3 Management of neuroleptic malignant syndrome... 122 Table 13.1 Management of chronic obstructive pulmonary disease... 125 Table 13.2 Management of acute asthma exacerbations... 127 Table 13.3 Drug-induced pulmonary diseases... 129 Table 14.1 Contrast-induced nephropathy prevention strategy... 131 Table 14.2 Pharmacological management of acute kidney injury... 133 Table 14.3 Management of acute uremic bleeding... 134 Table 14.4 Drug-induced renal diseases... 135 Table 14.5 Management of acute hypocalcemia (serum calcium < 8.5 mg/dl)... 136 Table 14.6 Management of acute hypercalcemia (serum calcium > 12 mg/dl)... 137 Table 14.7 Management of acute hypokalemia (serum potassium < 3.5 meq/l)... 138 Table 14.8 Management of acute hyperkalemia (serum potassium 5.5 meq/l)... 139 Table 14.9 Management of acute hypomagnesemia (serum magnesium < 1.4 meq/l)... 141

xvi List of Tables Table 14.10 Table 14.11 Table 14.12 Table 14.13 Table 14.14 Table 14.15 Table 14.16 Management of acute hypermagnesemia (serum magnesium > 2 meq/l)... 141 Management of acute hyponatremia (serum sodium < 135 meq/l)... 142 Management of acute hypernatremia (serum sodium > 145 meq/l)... 146 Management of acute hypophosphatemia (<2 mg/dl)... 148 Management of hyperphosphatemia (>5 mg/dl)... 148 Management of acute primary metabolic acidosis (ph < 7.35)... 149 Management of acute primary metabolic alkalosis (ph > 7.45)... 152