Norepinephrine (Levophed) - Effect on cardiac output at higher doses
Answer
Can increase cardiac output slightly
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Norepinephrine (Levophed) - Storage precaution
Answer
Protect from light
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Norepinephrine (Levophed) - Standard starting dosage
Answer
0.02mcg/kg/min (ensure rate needs are adjusted if higher than standard)
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Norepinephrine (Levophed) - Titration interval
Answer
Titrate 0.02mcg/kg/min every 5 minutes; titration goal MAP
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Norepinephrine (Levophed) - Maximum dosage
Answer
2mcg/kg/min
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Norepinephrine (Levophed) - Standard concentration (dose)
Answer
4mg in 250 mL of NSS
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Norepinephrine (Levophed) - Concentrated dose
Answer
8mg in 250 mL of NSS
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Norepinephrine (Levophed) - Maximum concentration (pharmacy made only) for fluid overloaded patients
Answer
32mg/250mL
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Norepinephrine (Levophed) - Treatment for extravasation
Answer
Phentolamine
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Norepinephrine (Levophed) - Administration route
Answer
Central line administration is required unless physician orders allow administration into a large peripheral IV
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Nitroglycerin - Indications
Answer
Angina relief via sublingual tablet or IV gtt, Hypertension, Spasm prophylaxis of radial artery graft site after CABG, Pulmonary edema
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Nitroglycerin - Cellular mechanism of action
Answer
Converted to nitric oxide (NO) which relaxes smooth muscle causing vessel dilation
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Nitroglycerin - Observable effects (main)
Answer
Angina relief, Decrease filling pressures (CVP/PCWP), Decrease MAP, May see reflex tachycardia (Think CO = SV x HR. Will be more pronounced if pt. is hypovolemic)
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Nitroglycerin - Sublingual dosage for angina
Answer
0.4mg tablet, repeat up to 3 doses
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Nitroglycerin - IV dosage for preload and afterload reduction
Answer
IV Nitroglycerin dosage is dependent on desired effect. Some sources say <50mcg/min preload/afterload reduction predominates. >50mcg/min arterial dilation will also occur.
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Nitroglycerin - Titration interval for IV
Answer
Usually in 5-10mcg/min increments q5min (look at order)
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Nitroglycerin - Onset of action
Answer
1-3min/ duration 10-20mins
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Nitroglycerin - Radial artery spasm dose
Answer
1-10mcg/min
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Nitroglycerin - Nursing consideration for angina relief
Answer
Decreased preload and afterload both lower cardiac oxygen demand. Additionally, directly dilates coronary vasculature and may decrease platelet aggregation both leading to better coronary blood flow.
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Nitroglycerin - Contraindication if RV infarct suspected
Answer
Don't use if RV infarct suspected. What leads? II, III, aVF. Why? Preload reduction will cause profound hypotension.
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Nitroglycerin - Contraindication related to Viagra
Answer
If Viagra taken within 24 hours, Nitroglycerin contraindicated d/t profound hypotension
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Nitroglycerin - PMC status
Answer
PMC status gtt should only be titrated for anginal relief (verify orders)
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Nitroglycerin - Effect on heparin resistance
Answer
May cause heparin resistance which may lead to sub-therapeutic PTT levels
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Nitroglycerin - Side effects
Answer
Headache, Hypotension, Reflex tachycardia (thus no benefit of decreased O2 demand), Methemoglobinemia (seen at high doses and if on gtt for several days), Cyanosis, Lactic acidosis, lower SaO2 than expected based on PaO2, Chocolate colored blood (Treat with Methylene Blue)
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Milrinone - Indications
Answer
LV dysfunction and RV dysfunction (d/t pulmonary vascular dilation)
Increase in CO/CI, Decrease SVR/MAP (lower afterload → better stroke volume), Decrease in CVP/PCWP
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Milrinone - Cellular mechanism
Answer
PDE (enzyme in cardiac muscle) that metabolizes cAMP. Milrinone inhibits the action of PDE leading to increase cAMP. More cAMP causes Ca+2 to flow into cell which leads to increased contractile force. Has a synergistic effect with B1 agonists on contraction. This is because B1 agonist increase cAMP and Milrinone inhibits cAMP breakdown. Overall more Ca+2 → increase contraction force.
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Milrinone - Dosage range
Answer
0.125-0.75 mcg/kg/min
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Milrinone - Potential side effect and management
Answer
Pt may become hypotensive. Providers may add vasopressors (Levophed/Vasopressin to counteract this).
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Milrinone - Onset and duration of action
Answer
Milrinone has rapid onset action but takes a while to reach steady state (ie maximal effect). May take up to 6 hours see full effect of dose! Half life 2-3hrs. Thus, it takes longer to see effect when decreasing dosage. Ask provider when they would like you to shoot your CO/CI.
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Milrinone - Electrolyte monitoring
Answer
May cause tachyarrhythmias, although probably less than other inotropes (ie dobutamine/EPI). As always, monitor your electrolytes!
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Milrinone - Administration route
Answer
Pt can go home on milrinone gtt.
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Milrinone - RN titration responsibility
Answer
RN doesn't titrate medication
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Epinephrine (Adrenaline) - Typical uses
Answer
Sepsis, ACLS, Anaphylaxis
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Epinephrine (Adrenaline) - Effect on SVR and BP
Answer
Increases SVR and BP
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Epinephrine (Adrenaline) - Effect on bronchioles
Answer
Bronchodilation
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Epinephrine (Adrenaline) - Effect on inotropy, HR, and CO
Epinephrine (Adrenaline) - Overall mechanism of action
Answer
Epinephrine acts on both beta-1 adrenergic, beta-2, and alpha-1 adrenergic receptors. Low doses of epinephrine increase cardiac output due to stimulation of the Beta-1 receptor inotropic and chronotropic effects. Alpha 1 stimulation causes vasoconstriction, whereas the Beta-2 stimulation causes vasodilation.
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Epinephrine (Adrenaline) - Standard concentrations