CORDARON – AMIODARON

ACTION Anti arrhythmic properties Reduce sinus automaticity Anti angina properties

INDICATONS Treatment of severe rhythm disorders not responding to other therapies both

atrial and ventricular rhythm disorders Tachycardia associated with Wolff Parkinson White Syndrome Ventricular rhythm disorders

DOSE IV infusion loading dose 5 mg/kg administed in 250 mls of 5% Dextrose over

a period of 20 minutes – 2 hours Rate of infusion is adjusted on basis of results Maintenance dose : 10 – 20 mg/kg/24 hours

(usually 600 – 800 mg/24 hours and up to 1200 mg/kg/24 hours) IV close is usually followed up with oral dose

ROUTE IV Oral

PRECAUTIONS Patients must be monitored when given IV Amiodaron Hypotension Severe Respiratory insufficiency Hyperthyroidism

GTN – NITROCINE

ACTION Veno dilation

INDICATONS Angina Pectoris Rapid control of hypertension during cardiac surgery Maintain controlled hypotension during surgical procedures

DOSE Dilution 10 mg in Normal Saline or 5% Dextrose in 50 mls Peri Operative myocardial ischemia 15 – 20 mcg/min UAP : 10 mcg/min

ROUTE IV

PRECAUTIONS/SIDE EFFECTS Headache Hypotension Tachycardia Palpitation

DOPAMINE

ACTION Stimulate β1 adrenergic cardiac receptors Stimulate α adrenergic effect Increase Cardiac Output (medium to high dose)

INDICATONS Hypotension Septic shock

DOSE 50 mls Dextrose with 200 mg Dopamine 1 – 20 mcg/kg/min

ROUTE IV CVP access preferred

PRECAUTIONS Increased Heart Rate Arrhythmia Nausea and Vomiting

DOBUTAMINE

ACTION Synthetic sympathomimetic amine Stimulate β1 and α1 adrenergic receptors Increase Cardiac Output Minimize myocardial oxygen demand

INDICATONS Decreased Cardiac Output Pulmonary congestion Hypotension

DOSE 50 mls 5% Dextrose or Normal Saline with 250 mg Dobutamine 1 mcg – 20 mcg/kg/min

ROUTE IV

PRECAUTIONS Tachycardia Myocardial ischemia Nausea and Vomiting Headache

LIDOCAINE

ACTION Suppress ventricular arrhythmias by decreasing automaticity It’s local anesthetic properties help to suppress ventricular ectopy after AMI

INDICATONS Treatment of VT and VF that is refractory to electrical DC shocks

DOSE 1 – 2 mg/kg start then 1 – 4 mg/min Infusion 500 mg in 500 mls Normal Saline – ICCU Infusion 500 mg in 50 mls Normal Saline - ICU

ROUTE IV ETT use 2 – 2,5 times the IV dose (emergency use only)

PRECAUTIONS Excessive dose can cause neurological changes

o e.g. Fittingo Drowsinesso Psychosiso Twitching

NOR ADRENALIN

ACTION Stimulate β1 adrenergic cardiac receptors Stimulate α adrenergic effect Arterial and venous vasoconstriction Increase myocardial contractibility

INDICATONS Hypotension Septic shock

DOSE 50 mls Dextrose or Normal Saline with 8 mgs Nor Adrenaline: 50 mls with 8

mgs (160 mcs/ml)o Infusion 0,005 – 0,5 mcg/kg/min

ROUTE IV Must have CVP inserted

PRECAUTIONS Peripheral vasoconstriction Increased myocardial oxygen demand Arrhythmia

ATROPINE

ACTION Is a parasympatholytic drug. That enhances both sinus node automaticity and

atroventricular conduction via it’s direct vagolytic action

INDICATONS Symptomatic bradycardia

DOSE Cardiac arrest 0,5 – 1,0 mg IV

Repeat approximately every 3 – 5 minutes

ROUTE IV ETT 1 -2 mg diluted with approximately 5 mls Normal Saline

SIDE EFFECTS ↑ pulse Flushed and panus skin Blurred vision Dilated pupils

FENTANYL

ACTION Is a potent, lipid soluble synthetic opioid that is rapidly and widely

distributed to tissues

INDICATONS Pain relief Sedation

DOSE Infusion dilution: 50 mls Normal Saline with 500 mcg Fentanyl 1 – 4 mcg/kg/dose (adult 200 mcg) IM or IV Infuse 2 – 4 mcg/kg/hr

o < 25 kg: 100 mcg/kg in 50 mlo > 25 kg: 50 mcg/ml at 0,04 – 0,08 ml/kg in 50 ml/hr

Ventilated 5 – 10 mcg/kg start or 50 mcg/kg IV over 1 hourInfusion 5 – 10 mcg/kg/hr (amp. 50 mcg/ml at 0,1 – 0,2 ml/kg/hr)

ROUTE IV

PRECAUTIONS Respiratory depression Hypotension

PENTHOTAL

ACTION Acts on the brain and CNS to cause drowsiness

INDICATONS Assist to reduce intracranial pressure

DOSE Infusion dilution: 50 mls Normal Saline with 1000 mg Penthotal 3 – 5 mg/kg slowly start Then 1 – 5 mg/kg/hr

ROUTE IV

PRECAUTIONS Hypotension

MUSCLE RELAXANTS

TRACRIUM

IMPORTANT NO PATIENT SHOULD BE PARALYSED WITHOUT FIRST BEING

SEDATED TOM THE POINT OF UNROUSABILITY PATIENT MUST BE VENTILATED

DOSE Infusion dilution: 50 mls Normal Saline with 500 mg Tracrium 0,3 – 0,6 mg start, then 5 – 10 mcg/kg/min IV

INDICATIONS To facilitate ventilation when adequate sedation alone is unable to:

o Increase chest wall complianceo Reduce peak airway pressureo Reduce the risk of barotraumaso Allow optimal gas exchangeo Facilitate permissive hypercapnia

To ensure physiological control in patient with raised intracranial pressure To control muscle spasm in Tetanus

PRECAUTIONS Histamine release, producing vasodilatation or bronchospasm (bolus dose

only) not seen with infusion of atracurium Protective reflexes abolished, risk of corneal abrasions, deep vein thrombosis Prolonged muscle weakness Neurological assessment is unreliable

MIDAZOLAM

ACTION Produce sleepiness or drowsiness and to relieve anxiety Used to maintain unconscious state in ICU

INDICATIONS Hypnotic Sedation

DOSE Infusion dilution: 50 mls Dextrose or Normal Saline with 90 mg Midazolam Sedation: 0,01 – 0,2 mg/kg/IV or IM up to 0,5 mg/kg Anesthesia: 0,5 mg/kg, then 2 mcg/kg/min

ROUTE IV

PRECAUTIONS Respiratory depression and over sedation Hypotension May impair verbal contact and cooperation

MORPHINE

ACTION Analgesic effect Reduces systemic vascular resistance Reduces myocardial oxygen requirement

INDICATIONS Treatment of cardiac related pain and anxiety Useful in treating acute cardiogenic pulmonary oedema

DOSE Infusion dilution: 50 mls Normal Saline with 20 mg Morphine Administered in small incremental doses slowly over 1 -5 minutes until

desired effect achieved 0,1 – 0,2 mg/kg dose (adult 5 – 10 mg) IV 0,2 mg/kg/dose (10 – 20 mg adult) IM Infusion: 10 – 60 mcg/kg/hr

ROUTE IV

PRECAUTIONS Respiratory depression Hypotension

PRECEDEX – Dexmedetomedine HCL

ACTION Provide sedation and analgesia without respiratory depression Additional symphatolytic properties include less anxiety hemodynamic

stability Alpha 2 adrenoreceptor agonist

INDICATIONS Sedation with analgesic

DOSE Infusion dilution: 200 mcg Precedex in 48 mls of Normal Saline or water for

injection Loady dose I mcg/kg over 10 minutes Then followed by maintenance infusions : 0,2 to 0,7 mcg/kg/hr

ROUTE IV

PRECAUTIONS Hypotension Bradycardia

LASIX

ACTION Rapidly acting diuretic that inhibits reabsorption of sodium and chloride in

ascending loop of Henle Promotes a diuresis

INDICATIONS Treatment of acute renal failure Treatment of pulmonary congestion associated with left ventricle dysfunction

DOSE Infusion dilution: 50 mls Normal Saline with 400 mg Lasix Initial dose usually is: 0,5 – 1 mg/kg (adult 20 – 40 mg) IV 6 – 24 hr IV infusion at rate of 0,25 – 0,75 mg/kg/hr

ROUTE IV

PRECAUTIONS Dehydration Hypotension Electrolyte imbalance Metabolic alkalosis

SUXAMETHOIMUM

ACTION Paralysis short acting

INDICATIONS For intubation inductive

DOSE 1 – 2 mg/kg BW bolus

o Neonate 3 mg/kg doseo Child 2 mg/kg doseo Adult 1 mg/kg doseo IM: double IV dose

ROUTE IV or IM

PRECAUTIONS Increase potassium Tachycardia

ACTRAPID (BIOSYNTHETIC HUMAN INSULIN)

ACTION Reduction of blood glucose level Time of onset ½ hour. For maximal effect 1 – 3 hours with duration of action

8 hours

INDICATIONS Treatment for Insulin Dependent Diabetes Mellitus

DOSE 50 units Actrapid in 50 mls Normal Saline Infusion 4 units/hr check BLS every 8 hours

SKDIAS SCALE – BOLUS < 100 mg/dL give 8 unit 100 – 150 mg/dL give 4 unit 151 – 200 mg/dL give 8 unit 201 – 250 mg/dL give 12 unit 251 – 300 mg/dL give 16 unit >300 mg/dL call doctor

ROUTE IV, SC

PRECAUTIONS Hypoglicemia

Check BLS every 2 – 4 hours or more frequently as required

CARE OF THE INTUBATED PATIENT

REASONS FOR INTUBATION

Several indication for intubation exist:o Airway obstruction – airway oedema, epiglottiso Secretion management – ETT provides a conduit for suctioningo Airway protection – from regurgitation/aspiration due to decreased

LOC/FICS and,o Need for high concentration oxygenation, ventilation or sedation/general

anesthesia

POSSIBLE COMPLICATION OF INTUBATION

Aspiration Trauma Bradycardia – Vagal stimulation Hypoxaemia (attempts limited to 30 sec) Right main bronchus intubation Oesophageal intubation Tube malposition Tracheal necrosis Pharyngeal oedema Mouth, lip or nare preassure – sore development

CONTINOUS MANDATORY VENTILATION

CMV (assist/control) RR, Vt (8 – 10 mls/kg), FiO2, peak flow and waveform all constant Breaths initiated can be:

o Mandatory: ventilator/operator initiatedo Assist: patient initiated (retains characteristics of mandatory breath)

If Pt ↑ RR = ↑ minute volume

CONTINOUS POSITIVE AIRWAY PRESSURE

CPAP Spontaneous mode Positive pressure applied to airway throughout respiratory cycle useful for alveolar recruitment (↑ FRC) = optimizing oxygenation

PEEP ~ CPAP except CPAP term used for spontaneous mode

SYNCHRONISED INTERMITTENT MANDATORY VENTILATION

SIMV timed to allow for pt effort

o timing divides each breath cycle into mandatory breath phase and spontaneous phase

o @ 12 bpm breath cycle = 5 secs Any breaths taken in excess of RR set, are spontaneous phase Advantages

o Guarantees minimum minute volume in absence of patient efforto Assist + mandatory breath = total RRo Additional respiratory effort = spontaneous breathso ↓ SIMV rate allows weaning

Disadvantageo Can still get pt/ventilator dysynchrony

PRESSURE SUPPORT

Only active in SIMV + CPAP Range = 1 – 70 cmH2O When pt initiates breath gas delivered at rate to achieve and maintain PS level above

PEEP Can be volume or flow triggered

o PS + flowby = flow triggeringo PS (no flowby) = volume triggered

Advantageso Augment tidal volumeo Overcome resistance of artificial airwayo Reduce work of breathing (controversial)

Disadvantageso Static

CARE OF THE ICU PATIENT DURING TRANSPORT

Security of the ETT – to avoid dislodgement we ensure there is sufficient oxygen in bottle

Stability of unstable patient – may require paralyzing/sedative agents prior to transport Haemodynamically unstable patient may require inotropic drugs/fluid challenges, ensure

adequate supply Emergency equipment

PENGENCERAN OBAT TITRASI

Atropine 16 mcg in 50 mls Normal Saline

Diazepam 100 mcg in 50 mls Normal Saline

Dobutamine 250 mg in 50 mls Dextrose or Normal Saline

Dopamine 200 mg in 50 mls Dextrose

Fentanyl 500 mcg in 50 mls Normal Saline

GTN - Nitrocine 10 mg in 50 mls Normal Saline or 5% Dextrose

Lasix 400 mg in 50 mls Normal Saline

Lidocaine 500 mg in 500 mls Normal Saline – ICCU500 mg in 50 mls Normal Saline – ICU

Midazolam 90 mg in 50 mls Dextrose or Normal Saline

Morphine 20 mg in 50 mls Normal Saline

Nor Adrenaline 8 mg in 50 mls Normal Saline or Dextrose

Penthotal 1000 mg in 50 mls Normal Saline

Precedex 200 mcg in 50 mls Normal Saline or water for injection

Soxamethoimum bolus

Tracrium 500 mg in 50 mls Normal Saline

PEDOMAN TERAPI OBAT EMERGENCY

DI RUANG TERAPI INTENSIF

INSTALASI RAWAT INTENSIF TERPADU

RUMAH SAKIT UMUM PUSAT SANGLAH

DENPASAR

2007