ABCIXIMAB is a GP IIb/IIIa inhibitor, used as an adjunct to PTCA or atherectomy to prevent acute cardiac ischemia complications in patients at high risk for abrupt closure of the treated coronary vessel. It is intended to be used with aspirin and heparin therapy. ABCIXIMAB is FDA approved for patients with non–Q-wave MI or unstable angina with planned PCI within 24 hours.

Angiotensin converting enzyme (ACE) inhibitors prevent the production of angiotensin II, a potent vasoconstructor that stimulates the production of aldosterone by blocking its conversion to the active form. The result is systemic vasodilation.

Acetadote is the only FDA-approved IV formulation of acetylcysteine (Mucomyst), developed specifically for use after ingestion of a hepatotoxic dose of acetaminophen.

Adenosine is a first-line antiarrhythmic used to treat PSVT and WPW. It has an unusually rapid onset, and its half-life is less than 10 seconds.

Alteplase (Activase, t-PA, rt-PA, Cathflo) is a tissue plasminogen activator that binds to fibrin, converting plasminogen to plasmin. This conversion allows the drug to dissolve the clot causing the blockage and restores blood flow and oxygen to the affected area.

A smooth muscle relaxant, aminophylline is sometimes useful in asthma and bronchospasms.

Mix: 500 mg in 500 mL D₅W or 0.9 NS.

Infuse: If patient does not receive long-term maintenance theophylline, an IV loading dose of 5.6 mg/kg over 30 minutes is required. Maintenance IV dose ranges from 0.2 to 0.9 mg/kg/hr. Titrate infusion to therapeutic drug level of 10 to 20 mcg/mL.

Amiodarone is a class III antiarrhythmic agent used for a wide variety of atrial and ventricular tachyarrhythmias, and for rate control of rapid atrial arrhythmias in patients with impaired LV function when digoxin has proven ineffective.

Intended for use with aspirin, Angiomax is a direct thrombin inhibitor with a naturally reversible mechanism of action. It is used as an anticoagulant (and as an alternative to unfractionated heparin) in patients undergoing percutaneous transluminal angioplasty. More recently, it has been approved for use in patients with or at risk of heparin-induced thrombocytopenia and thrombosis syndrome, who are undergoing percutaneous coronary intervention.

An anticoagulant that is a direct thrombin inhibitor, used primarily in patients diagnosed with HIT (heparin induced thrombocytopenia).

Mix: 250 mg in 250 cc 0.9 NS to make a 1 mg/1 mL concentration.

Infuse: Initial adult dosage at 2 mcg/kg/min continuous IV infusion. After initial dose, dose may be adjusted (not to exceed 10 mcg/kg/min) until PTT is 1.5 to 3 times the initial baseline (but not to exceed 100 seconds). Dose modification required for hepatic impairment, but not for renal impairment.

Considerations: Monitored by PTT.

An antianxiety and amnestic, Ativan is used frequently in the ICU setting for sedation.

Mix: Best solubility is in concentrations of 0.1 mg/mL or 0.2 mg/mL. Dilute in D₅W or NS.

Load (for sedation): 2 mg IV (may not be necessary if patient is receiving intermittent benzodiazepines, e.g., diazepam or midazolam).

Maintain: Continuous infusion of 0.5 to 1 mg/hr (0.25 mg/hr if patient is less agitated or has cardiorespiratory problems). Titrate to achieve sedation. Increase in 1-mg increments. Up to 5 to 10 mg/hr has been used. When sedation is adequate, wean to lowest amount needed.

Also known as a “rally bag,” this IV mixture (most commonly used for chronic alcoholics) contains vitamins and minerals to replenish nutritional deficiencies.

Mix: 1 L 0.9 NS with

Infuse: Typically infused over 4 to 8 hours.

Beta receptors are found in a number of places in the body: heart, lung, arteries, brain, and uterus, to name a few. Like a key in a lock, beta blocker drugs (also known as beta adrenergic blocking agents) fit into the beta receptor sites and prevent epinephrine and other catecholamines from binding to the receptors that cause a response.

The body has two main beta receptors:

Bumex is a potent loop diuretic with rapid onset and short duration. It is indicated for treatment of edema associated with CHF and hepatic or renal dysfunction. Usual dose is 0.5 mg to 2 mg IV or PO daily, but use of a continuous drip in the ICU is not uncommon. Since 1 mg of Bumex has the potency equivalent of 40 mg of furosemide, a drip rate of 0.1 to 1 mg/hr is standard, though higher doses are sometimes seen. In a small number of patients, IV infusion may result in severe muscle cramps or stiffness. This complication appears to be dose related, and generally subsides when the drug is discontinued. Patients who experience this reaction may need to be diuresed with equivalent doses of furosemide (Lasix) instead.

Calcium is an electrolyte that helps maintain the function of the nervous and muscular systems. It is also important in blood coagulation.

Calcium channel blockers inhibit calcium influx across cardiac and smooth muscle cells, resulting in decreased myocardial contractility and decreased oxygen demand while dilating coronary arteries and peripheral arterioles.

There are many calcium channel blockers on the market, and their differences vary widely. For example, amlodipine (Norvasc) has very little effect on heart rate and contraction, so it is a good choice for use in individuals who have heart failure or bradycardia. Conversely, drugs like diltiazem (Cardizem) have their greatest effect on the heart and in reducing the strength of contraction, so they are best utilized for tachycardias.

Cerebyx is indicated for short-term parenteral administration when other means of phenytoin administration are unavailable, inappropriate, or deemed less advantageous. It is used for control of generalized convulsive status epilepticus and prevention and treatment of seizures occurring during neurosurgery. Cerebyx should always be prescribed in phenytoin sodium equivalent (PE) units.

Dosage: Before IV administration, Cerebyx should be diluted in D₅W or 0.9% NS for injection to a concentration ranging from 1.5 to 25 mg PE/mL.

Load: 10 to 20 mg PE/kg given IV or intramuscularly. If administered IV, infuse at a rate no greater than 150 mg PE/min.

Maintenance: 4 to 6 mg PE/kg/day

Also known as parasympathomimetics, cholinergic drugs produce the same effects as the body’s parasympathetic nervous system (the part of the peripheral nervous system responsible for dealing with everyday activities such as digestion, sphincter muscle relaxation, salivation, and reducing heart rate and blood pressure). Nerve impulses in the parasympathetic nervous system are transmitted from one nerve junction to another with the help of acetylcholine, and cholinergic agents work by either mimicking the effect of acetylcholine or blocking the effects of acetylcholinesterase (giving acetylcholine a longer life). Cholinergic drugs are frequently used in the diagnosis of myasthenia gravis and are widely used in surgery to reduce urinary retention and to counteract the effects of some muscle relaxants given.

Conversely, anticholinergic drugs are used to inhibit parasympathetic nerve impulses by blocking the binding of acetylcholinergic to receptor sites in the nerve cells. Anticholinergics are used to treat a variety of disorders such as gastrointestinal cramps, urinary bladder spasm, asthma, motion sickness, muscular spasms, and as an aid to anesthesia.

Chronotropic agents affect the heart rate. Positive chronotropes (e.g., epinephrine and Isuprel) will increase the heart rate, while negative chronotropes (e.g., beta blockers, calcium channel blockers, such as diltiazem) will decrease the heart rate.

A rapid-acting vasodilator used for short-term management (up to 48 hours) of severe hypertension, including malignant hypertension with deteriorating end organ function.

Mix: In 0.9% NS or D₅W as directed in the following table:

Infuse: Start dosage at 0.03 to 0.1 μg/kg/min, and titrate every 15 minutes by 0.05 to 0.1 μg/kg/min until desired blood pressure is achieved. No bolus is required.

Coumadin (warfarin) is an anticoagulant that inhibits vitamin K and directly interferes with clotting factors II, VII, IX, and X.

Dosage: 2 to 10 mg PO daily, based on PT ratio (1.5–2.5 × control) or INR of 2 to 3.

Diltiazem is a calcium channel blocker used in SVT, atrial fibrillation, angina, and hypertension.

Dosage: 0.25 mg/kg IV push over 2 minutes (average 20 mg IV). If no response, may repeat in 15 minutes at 0.35 mg/kg over 2 minutes.

Mix: 250 mg in 250 mL D₅W

Infuse: 10 to 15 mg/hr; titrate to heart rate.

Dobutamine is a synthetic sympathomimetic catecholamine with inotropic, chronotropic, and vasodilator effects. It is useful in treating heart failure (especially with an increase in SVR and PVR by increasing contractility with no significant increase in heart rate.) The blood pressure is increased because of the increased cardiac output. The vasodilatory effects of the drug, however, are more pronounced in some patients, and may actually cause a decrease in the blood pressure.

Infuse: 2 to 10 μg/kg/min (can go up to 40 μg/kg/min with physician approval)

Mix: 250 mg in 250 mL D₅W or 0.9% NS

Or mix: 500 mg in 250 mL D₅W or 0.9% NS

Dopamine is a natural catecholamine that is the immediate precursor of norepinephrine. It is used to raise low blood pressure that is refractory to fluid therapy, to treat heart failure, and to correct hemodynamic imbalance in shock syndrome. Onset of the drug is rapid, usually 5 minutes, with duration lasting about 10 minutes.

Mix: 400 mg in 250 mL D₅W or 0.9% NS

Or mix: 400 mg in 500 mL D₅W or 0.9% NS

Or mix: 800 mg in 250 mL D₅W or 0.9% NS

Dromotropic agents affect atrial-ventricular (AV) nodal conduction. A positive dromotrope will increase the conduction (e.g., atropine sulfate), and a negative dromotrope will slow conduction (e.g., Lanoxin).