Top Drawer

Mark Bombulie, M.D.

About to be CA-3
Objectives
 Location with in top drawer
 Mechanism of action
 Concentrations
 Indications/contraindications
 Typical doses
 Side effects
 Discussion with attending required?
Propofol
Propofol
 Mechanism of action?
 GABA agonist
 Concentration?
 10 mg/ml
 Induction dose?
 1-2 mg/kg
 Side effects?
 Hypotension, decreased cardiac output, burning on injection
 Other uses?
 Sedation, anti-emetic
 Anti-emetic dose?
 10-20 mg
Etomidate
Etomidate
 Mechanism of action?
 GABA agonist
 Concentration?
 2 mg/ml
 Induction dose?
 0.2 – 0.6 mg/kg
 Side effects?
 Burning on injection, increased PONV, adrenal suppression
 Indication?
 “You aren’t going to give me that stuff that killed Michael
Jackson, are you?”
 In a patient who cannot tolerate the cardiovascular depressant
effects of propofol
Lidocaine
Lidocaine
 Mechanism of action?
 Na channel blocker
 Concentration?
 2% or 20 mg/ml
 Induction adjunct dose?
 1-1.5 mg/kg
 Side effects?
 Sedation, tinnitus, metallic taste, local anesthetic toxicity (>4
mg/kg or 7 mg/kg with epinephrine)
 Other uses?
 Multimodal analgesia (infusion of 2 mg/min)
 Ventricular arrhythmia treatment (1-4 mg/kg)
 Definitely contact your attending if you are considering
administration for a ventricular arrhythmia
Succhinylcholine
Succhinylcholine
 Mechanism of action?
 Depolarizing neuromuscular blockade
 Concentration?
 20 mg/ml
 Rapid Sequence Induction Dose?
 1-2 mg/kg (regular dose 0.3-1.1 mg/kg)
 Side effects?
 Tachycardia, bradycardia, hyperkalemia, MH trigger, histamine
release
 When to avoid use?
 History or family history of MH, muscular dystrophy, burns,
spinal cord injury, current hyperkalemia
 May be run as an infusion
Rocuronium
Rocuronium
 Mechanism of action?
 Non-depolarizing neuromuscular blockade
 Concentration?
 10 mg/ml
 Induction dose?
 0.6 mg/kg
 RSI induction dose?
 1 – 1.2 mg/kg
 Other notes
 Partial renal excretion, but not contraindicated in renal failure
 Most common cause of anaphylaxis in the OR
Phenylephrine
Phenylephrine
 Mechanism of action?
 Alpha-1 agonist
 Concentration?
 100 mcg/ml
 Typical dose?
 50-200 mcg
 Infusion rate?
 30 – 200 mcg/min
 Side effects?
 Reflex bradycardia, coronary ischemia at high infusion rates
Phenylephrine
 Contact your attending if:
 You are giving repeated doses with little change in blood
pressure
 You are planning on starting an infusion
Ephedrine
Ephedrine
 Mechanism of action?
 Beta agonist and norepinephrine release from adrenal gland
 Concentration?
 5 mg/ml
 Typical dose?
 5-10 mg
 Other notes
 Risk of tachyphylaxis with repeated dosing
 Higher concentration available for IM use (50 mg/ml)
Calcium Chloride
Calcium Chloride
 Mechanism of action?
 Increases cardiac output, may cause vasoconstriction
 Concentration?
 100 mg/ml
 Uses?
 Hypocalcemia, hypotension, protection of the myocardium from
hyperkalemia
 Typical dose?
 100-200 mg at a time (500-1000 mg total)
 Side effects?
 Arrhythmias with large, bolused doses, very uncomfortable for
awake patients (use calcium gluconate instead)
Vasopressin
Vasopressin
 Mechanism of action?
 Vasopressin receptor agonist
 Concentration?
 20 units/ml
 Typical dose?
 1-2 units (typically dilute to 1-2 units/ml)
 Infusion of 0.04 units/minute
 Indications?
 Hypotension refractory to phenylephrine (i.e. patient on an
ACEi/ARB), hypotension refractory to norepinephrine
Vasopressin
 ALWAYS contact your attending if you are thinking of using
 Central access preferred
 No receptors in the pulmonary circulation
 Good for patients with pulmonary hypertension who require
pressors
Epinephrine
Epinephrine
 Mechanism of action?
 Beta-1/2, alpha-1 agonist
 Concentration?
 1:10,000 or 100 mcg/ml
 Typical dose?
 Anaphylaxis – 10-20 mcg in escalating doses (dilute to 10
mcg/ml – “baby epi”)
 ACLS – 1 mg
 Infusion 1-10 mcg/min
 Side effects?
 Arrhythmias, lactic acidosis
 Contraindications?
 HOCM, SAM
Epinephrine
 ALWAYS contact your attending if you are thinking about
using
 However, do not delay in an emergency
Atropine
Atropine
 Mechanism of action?
 Anticholinergic
 Concentration?
 100 mcg/ml
 Indication?
 Bradycardia
 In adults, be sure to give at least 400 mcg; otherwise can get
a paradoxical bradycardia
Glycopyrrolate
Glycopyrrolate
 Mechanism of action?
 Anticholinergic
 Concentration?
 0.2 mg/ml
 Indications?
 Prevention of bradycardia/asystole from neostigmine use
 Remember to give even in a denervated heart (to avoid the
other less pleasant side effects of neostigmine)
 Anti-sialagogue
 Dose?
 Usually 0.2 mg per 1 mg of neostigmine
 0.2 mg to dry secretions for fiberoptic intubation
Esmolol
Esmolol
 Mechanism of action?
 Beta-1 selective antagonist
 Concentration?
 10 mg/ml
 Duration of action?
 Short, metabolized by plasma esterases
 Typical dose?
 10-30 mg bolus, may be run as an infusion (50-200 mcg/kg/min)
 Good idea to draw up for intracranial cases and for any patient
that cannot tolerate tachycardia
Metoprolol
Metoprolol
 Mechanism of action?
 Beta-1 selective antagonist
 Concentration?
 1 mg/ml
 Indications?
 Tachycardia (not due to insufficient opioid or due to
hypovolemia), perioperative beta blockade continuation,
patients undergoing CABG following an MI
Metoprolol
 Always contact your attending if you are considering
administration
Labetalol
Labetalol
 Mechanism of action?
 Alpha-1/beta-1 antagonist
 Concentration?
 5 mg/ml
 Indications?
 Hypertension not due to pain
Labetalol
 Always contact your attending if you are considering
administration
Hydralazine
Hydralazine
 Mechanism of action?
 Direct arterial vasodilation
 Concentration?
 20 mg/ml
 Indications?
 Hypertension in a patient with bradycardia (not a first line
drug in the OR)
 Typical dose?
 5-10 mg
 Side effects?
 Tachycardia, drug-induced lupus erythematosus
Hydralazine
 Always contact your attending if you are considering
administration
Furosemide
Furosemide
 Mechanism of action?
 Loop diuretic, decreases CSF production
 Concentration?
 10 mg/ml
 Indications?
 Edema/volume overload, hypercalcemia, open aneurysm
clippings (decrease CSF production)
Furosemide
 Always contact an attending if considering administration
Ketorolac
Ketorolac
 Mechanism of action?
 Non-specific cox inhibitor
 Concentration?
 30 mg/ml
 Dose?
 30 mg, unless > 65 yo or < 50 kg or CrCl < 30, then 15 mg
 Contraindications (some relative)?
 Surgeries involving gastric anastamoses/suture lines,
intracranial surgery, history of GI bleed, renal dysfunction,
high dose, prolonged administration can cause problems with
spinal fusions
 Ask the surgical team prior to administration
Ondansetron
Ondansetron
 Mechanism of action?
 5-HT3 antagonist
 Concentration?
 2 mg/ml
 Dose?
 4 mg
 Side effects?
 Prolonged QT, headache
Dexamethasone
Dexamethasone
 Mechanism of action?
 Glucocorticoid
 Concentration?
 4 mg/ml
 Uses?
 PONV, airway edema, brain edema
 Never bolus in an awake patient
Diphenhydramine
Diphenhydramine
 Mechanism of action?
 Anti-histamine
 Concentration?
 50 mg/ml
 Indications?
 Anaphylaxis, “pre-treatment”
Neostigmine
Neostigmine
 Mechanism of action?
 Acetylcholinesterase inhibitor
 Concentration?
 1 mg/ml
 Dose?
 0.04-0.07 mg/kg, max dose 5 mg
 Side effects?
 Bradycardia/asystole, urination, defecation
Naloxone
Naloxone
 Mechanism of action?
 Opioid receptor antagonist
 Concentration?
 400 mcg/ml – be sure to dilute to 40 mcg/ml
 Typical starting dose?
 40 mcg
 Indication?
 Reversal of an overzealous narcotization
 Side effects?
 Rapid opioid withdrawal, pulmonary edema
Albuterol
Albuterol
 Mechanism of action?
 Beta-2 agonist
 Indication?
 Bronchoconstriction, wheezing, hyperkalemia
 Dose?
 Pick a number of puffs.
Normal Saline (PF)
Normal Saline (PF)
 Preservative free vial
 Indication?
 Dilution of an epidural or intrathecally administered
medication
Not in the top drawer?
 Controlled substances (duh)--pharmacy
 Infusions (lidocaine, phenylephrine, nicardipine, etc)--
pharmacy
 Local anesthetics (for epidural bolusing—want PF)--
pharmacy
 1:100,000 epinephrine syringe (“baby epi”)--pharmacy
 Cisatracurium--pharmacy
 Tranexamic acid--pharmacy
 Commonly used antibiotics (cefazolin, cefoxitin, clindamycin)
can be obtained from the Pyxis in holding or OR corridor
 For others, call pharmacy
 Potassium chloride--Pyxis
When in doubt…
 Ask your attending.
 If the circulator gives you some mysterious drug to
administer…
 Call the OR pharmacy before you push it (2-4897)
Questions?