High Alert Medications

Enalapril:

imrpoves left ventricle dysfunction in acute myocardial infarction lenghtens progression for congestive heart failure dose - 1.25mg IV in 5 min, then 1.25 mg IV q6hrs

potassium chloride (KCL):

increases cardiac rhythm medication risk for arrhythmias, heart block, cardiac arrest NEVER administer IV push tachycardia could casue adverse event during potassium therapy if injected rapidly (exceeding 10mEq/hr) or the dose is too high it will cause cardiac arrest infusions must be IV pump allow substitution of oral KCL for IV KCL when appropriate assess for pain and phlebitis when transfusing concentration of 40mEq/liter through a peripheral vein

Dopamine and Dobutamine:

subject to mixup due to similar names IV flowrates are confusing because they are based on micrograms/kg/min

xylocaine (lidocaine):

treatment of ventricular arrhythmias and ventricular tachycardia reduces refractory period, affects automatism use only in single-dose vials do not place vials with more than 500mg in patient care areas, single dose vials reduce risk of overdose and eliminate risk of contamination used premixed and adequately labeled solutions

Hypertonic dextrose (dextrose 50%):

treats hyperglycemia

Calan (verapamil):

treats hypertension reduces heart overload and myocardial contraction

Chloral Hydrate and durgs used for pediatric ambulatory sedation:

used for sedation in abulatory setting overdoses occur because there are 2 strenghts avilable: 250mg/5mL, and 500mg/5mL it is somtimes ordered in terms of volume and not miligrams which causes more errors only proper trained staff can administer chloral hydrate do not allow home use order only in miligrams and not in volume

lidocaine:

ventricular fibrilaltion ventricular taquicardia doses - lidocaine 1mg to 1.5mg IV push, repeat every 5-10min if necessary for 3 doses

procainamida:

ventricular taquicardia paroxymal supraventricular tachycardia atrial fib doses - 20mg/min IV infusion

multifocal atrial tachycardia:

verapamil 2.5mg to 5mg every 15 to 30 min times 3 doses

benzodiazepines (midazolam or versed):

when using midazolam monitor vitals (pulse oximetry, have resucitation equipment in the area) restrict access - do not use midazolam for preoperative sedation except in the OR, this is because the appropirate monitoring equipment might not be available

adrenaline (epinephrine):

acts on alpha and beta receptors action on alpha receptors reduces vasodilatation reduces vascular permeability that occurs during anaphylactic reaction, said reaction can lead to intravascular volume loss and hypotension

diltiazem:

acts on atrioventriuclar node for the treatment of atrial fibrillation used after adenosine for the treatment of supraventricular taquicardia dose - diltiazem 15mg to 20mg Iv in 2 min, repeat in 15 min if necessary, if necessary prepare a maintenance infusion

nitroprusside:

hypertensive cirsis congestive heart failure

heparin:

acute myocardial infarction initial bolus 4,000 IU/mL > continue with 1,000 IU/hr > take PTT after 3 hours if U is used instead of units the error is 10x greater associated with drug allergies and thrombocytopenia separate the storage of all drugs ordered in units standarize the dosing using weight based protocols infusion pump rate settings and line placement on dual channel pumps chekced by 2 persons use only free flow protected pumps store therapeutic heparin preparations and catheter drainage together correct the sequence to drain a central line with heparin - drain with saline > infsue medication > drarin with saline > drain with heparin

supraventricular tachycardia:

adenosine 3 doses as necesry adenosine 6mg IV wait 1-2min > adenosine 12mg IV wait 1-2min > adenosine 12mg IV wait 1-2 min digoxin 0.1mg to 0.5 mg IV diltiazem 15mg to 20mg IV repeat in 15 min if necessary

paroxymal supraventricular tachycardia:

adenosine 3 doses as needed - 6mg IV wait 1-2min > 12mg IV wait 1-2 min > 12 mg IV wait 1-2 min after adenosine administration - diltiazem 5mg to 20mg (repeat in 15 min if necessary > procainamida 20mg IV > verapamil 2.5 to 5mg every 15 min and 3 doses if necessary

bradicarida and acute coronary syndrome:

administer atronpine 0.5mg IV push, repeat 3-5 min if persists

Asystole:

administer atropine 1mg IV push, repeat every 305 min is assytole persists

Aspirin:

administer in all patients with acute coronary syndrome (ACS) 160 to 325mg PO or rectal

Sodium bicarbonate:

administered when pH is less than 7.2 for reducing acidosis effects over teh cardiac function most frequently used alkaline solution administered IV for acute metabolic acidosis acidosis correction can lead to metabolic alkalosis and hypokalemia and can also lead to hypernatremia and hyperosmolarity (water retention and liquid overload) nursing treats diabetes miellitus and renal failure instead of the acidosis itself

Intropin (dopamine):

adrenergic (sympatomemetic) imitates sympathetic nervous system fight or flight response by stimulating alpha and beta adrenergic receptors it is a vasopressor or vasocontrictor and increases strength and frequency of myocadial contraction tissue necrosis is common in dopaine therapy for vassopressor effect administer 2-5mcg/kg/min have poster cards with the sandard doses to reduce problems with dopamine

High alert medications

adrenergic agents (epinephrine< isoproterenol, norepinephrine) cancer chemotherapeutic agents benzodiazepines intravenous calcium IV heparin thrombolytics and thrombin inhibitors warfarin drugs used for ambulatory pediatric sedation (chloral hydrate, ketamine, midazolam) IV digoxin IV magnesium hypertonic saline insulin phosphate salts potassium chloride IV lidocaine neuromuscular blocking agents narcotics and opiates (patient controlled analgesia [PCA] )

verapamil:

alternative medication after adneosine used for paroxymal supraventricular tachycardia atiral fib multifocal atiral tachycardia doses - 2.5mg to 5mg administer in 2 min every 15 to 30 min up to 3 doses

Magnesium sulfate:

anti seizure errors have resulted from abbreviations "MS" or "MSO4" for morphine sulfate and "MgSO4" for magnesium sulfate

Bretylol (bretillyum):

antiarrhythmic

Inderal (proponolol):

antiarrhythmic antianginal

metoprolol, atenolol, propanolol, labetalol:

betablockers administer to all patients with rule out myocardial infaction and unstable angina reduces ventricular fibrilation incidence use to convert to normal sinus thythm after administering adenosine dose - metoprolol 5mg in 5 min until 15mg if necessary

dopamine (IV infusion):

bradycardia (after atropine) hypotension

Isuprel (isoproterenol HCL):

bronchodialator antiasthmatic

Hypertonic saline:

can causes dangerous changes in serum sodium concentrations is floor stocked in many areas 5% saline has been confused with D5W/NS 3% saline has been confused with 0.3% saline only allow commercially available standard concentrations of sodium chloride outside of pharmacy

epinephrine:

cardiac arrest bradicardia severe hypotension anaphylaxis doses - epinephrine 1mg every 3-5 min to resuscitate, continuous infusion inf necessary before administering adrenergic agents use a second nurse to independently check the drug and dose and pump settings use cardiac monitors on all patients with central line

nitroglicerin:

chest angina acute myocardial infarction congestive heart failure

morphine sulfate:

chest pain in acute coronary syndrome caute cardiogenic pulmonary edema

dobutamina (IV infusion):

congestive heart failure lung congestion

atiral fibrillation:

digoxin 0.1mg to 0.5mg IV adenosine 6mg IV wait 1 to 2 min doses - adenosine 12mg IV wait 1 to 2 min > adenosine 12mg IV wait 1 to 2 min diltiazem 15 mg to 20 mg and repeat in 15 min if necessary procainamide in 20mg in infusion verapamil 2.5mg to 5mg every 15 min times 3 doses as needed

Lasix (furosemide):

diuretic

Neuromuscular blocking agents (NMB):

do not allow orders that say "used as needed for agitation" do not refer to NMB as "relaxants" protocols must be developed to ensure proper storage and administration; protocols should state that NMB are automatically discontinued when patient is extubated and removed from ventilator limit access to NMB for they are best handled by anesthesia personnel

Warfarin:

dosages are often improper drug food interactions are not recommended monitoring via prothrombin time/INR is not appropriate

Calcium Chloride (calcium gluconate)

electrolyte antacid

asystole:

epinephrine 1mg IV push every 3 to 5 min atropine 0.5mg IV push every 3 to 5 min norepinephrine sodium bocarbonate

bradycardia:

epinephrine 1mg IV push every 3 to 5 min dopamine norepinephrine sodium bicarbonate

severe cardiogenic shock:

epinephrine in 1m IV push every 3 to 5 min atropine 0.5 mg Iv push every 3 to 5 min norepinephrine

Chemotherapeutic Agents:

errors occur due to toxic nature and are often catastrophic requires certification before practitioners can prescribe or administer for chemo use computer order sets for all chemotherapeutic agents orders must include patient's height, weight

Dopamine:

extravasation is a problem when dopamine is given via peripheral vein tissue necrosis is common problem for vasopressor effect administer 2-5 mcg/kg/min have cards with standart units to avoid problems

Lanoxin (digoxin):

for heart failure treatment, increases contractility of left ventricle use for treatment of atrial fibrillation controlling ventricular response check apical pulse before administering potential risk of toxicity with digitalis, the first sign is ventricular tachycardia common adverse effect is dysrhythmia, premature ventricular contractions (PVC's) risk can be identified with irregular rhythm, pulse is greater than 100, patient complains of chest pain after medication administration

magnesium sulfate:

for treating hypomagnasemia doses - 1-2g diluted in 10mL dextrose water administer in 5-20 min

myocardial infarction:

heparin 4000 IU/mL nitroglycerin inderal (antiarrhythmic) bretyllium (antiarrhythmic)

atropine sulfate (chlorhidrate difenoxilate):

inhibits acetylcholine response relaxing the muscle and increasing the sphincter tone stimulates parasympathetic nervous system, produces stronger heart contraction

ventricular fibrillation:

lidocaine 1mg to 1.5 mg times 3 doses as needed

ventricular tachycardia:

lidocaine 1mg to 1.5 mg times 3 doses as needed procainamide 20mg/min in IV insusion

chest pain:

morphine sulfate nitroglycerine inderal

respiratory depression:

nalaxone

narcotics and opiates:

narcotic accidents are the most frequent and most reported hydromorphone and morphine are commonly confused (hydromorphone is 5x more potent than morphine) oral liquid morhpine is more potent (also has reported errors resulting in overdose) nalaxone or an equivalent must be available in all areas where narcotics are used

Narcan (nalaxone):

narcotic antagnoist

congestive heart failure:

nitroglycerine morphine sulfate nitroprusside (decreases blood pressure) lasix dobutamine (Iv infusion)

hypertensive cirsis:

nitroprusside

Atropine Sulfate:

number one treatment in sinus bradycardia second treatment after epinephrine or vasopressin for asystole

Phosphate salts (sodium and potassium):

phosphate is often given IV as potassium phosphate potassium overdoses occur sometimes phosphate replacement therapy should be done in oral route whenever possible

IV calcium:

prescribers often fail to specify the salt level the salt levels vary - gluconate contains 4.5 mEq of Ca++/gram <> calcium chloride contains 14 mEq/gram make certain that all calcium orders specify salt level

High alert medications of the Crash Cart: ----------------------------------------------- adenocard (adenosine):

reduces conduction time at the AV node restores normal sinus rhythm in patients with supraventricular taquicardia reduces arterial pressure by reducing peripheral resistance

Digoxin:

reduces ventricular response in atrial fibrillatioin used for trement of supraventricular taquicardia dose - 0.1mg to 0.5mg patient recieving digoxin is at potential rosk of toxicity with digitalis, early sign is ventricular tachycardia a mayor toxic effect is dysrhythmia, premature ventricular contraction irregular findings - irregular thythm in a patient who previously presented a regular thythm <> mayor frequency of 60 or more than 100/min <> patient complains of chest pain after medication administration has a narrow therapeutic range and has a number of drug interactions elderly are high alert for this medication, also patients who take quinidine provide patient education on importance of follow up blood test and potential overdose

Insulin:

regular insulin is the only insulin administered IV push monitor insulin levels in blood to avoid problems patient should ingest food near hour of insulin injection use the word units instead of U store heparin and insulin separately do 2 independent checks of all pump settings do not return insuling to the box you got it from after use

Adenosine:

related to Paroxysmal Upraventricular Tachicardia (PSTV) caused by affection at the atrioventricular node or at the sinoatrial node position patient in trendelenburg position administer 6mg IV ush, wait 1-2 min administer 12 mg IV push, wait 1-2 min administer 12mg IV push, wait 1-2 min

Aminophylline (theophylline):

relaxes smooth muscle (bronchodialator) and supresses response of airway stimulus adverse effects - hypotension, tachicardia, headache, emesis, blood flow alterations of the brain increases contraction force of the diaphrag muscles first dose can be administered directly through a catheter (IV push) theophylline levels should be measured 24 hours after starting infusion

nalaxone:

respiatory or neurologic depression caused by opiate intoxication

norepinephrine:

severe cardiogenic shock myocardial isquemic disease