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Friday, July 3, 2015

{UPDATED} 8 Drugs Every ICU Nurse Needs to Know

ICU, critical care, ACLS, nursing school, nurse, RN, pharmacology, cardiac, clinicals

8 Drugs Every ICU Nurse Needs to Know {EXPANDED}

Ask and ye shall receive!! Thanks to viral pinners on Pinterest, my previous (very brief) post on 8 Drugs Every ICU Nurse Needs to Know has gained some recent attention. Thank you, Peter, for your comment asking for a post about these drugs and what the nursing implications would be, what we need to monitor, and the contraindications, etc. Also, if you aren't already follow me on Pinterest so that you can keep up with new posts! Nurse Nightingale's Super Awesome Pinterest Profile!

Ok. Here it is folks!!

Just to save time, here is the list I had previously posted:

  1. Adenosine
    An endogenous nucleoside, slows conduction down through the AV node. Treats supraventricular tachycardia and sometimes atrial tachycardia (but I've never personally seen that). Extremely short half life- <10 seconds.
  2. Amiodarone
    Antiarrhythmic that effects the sodium, potassium, and calcium channels. Vasodilates. Used in V tach, V fib, and sinus tachycardia.
  3. AtropineAntocholinergic, enhances the conduction in the AV node. Drug of choice in treating bradycardia.
  4. Epinephrine
    Potent cathcholamine. Increases heart rate, blood pressure. Used to treat Asystole, V tach, V fib, or bradycardia.
  5. Lidocaine
    Antiarrhythmic used alternatively to Amioderone. Treats V fib or V tach.
  6. Procainamide
    Antiarrhythmic, used to treat sustained V tach. 
  7. Sotalol
    Beta Blocker. Treats A fib or A flutter.
  8. Vasopressin
    Synthetic antiarrhythmic. Used to treat Asystole, V tach, or V fib.

Nursing Implications, Side Effects, Contraindications

  1. Adenosine
    I've seen this used when the patient starts having supraventricular tachycardia (SVT) and vegal maneuvers (bearing down) are not converting the rhythm. The biggest things to note here are: hook the patient up to a 12 lead EKG, SLAM the Adenosine (although, the nurse is probably not doing the administration. It's most likely a doctor.), monitor the EKG for conversion of the rhythm.

    Typically, the first dose of Adenosine is 6 mg. If this doesn't convert the rhythm, you then administer 12 mg. If that doesn't work, you may administer 12 mg again. Again, there will be differences in hospital policies, but that's what I've seen. Remember, Adenosine has a short half life, (less than 10 seconds) so it needs to be pushed fast. Really fast.  It's kind of neat to watch the EKG as the heart reacts to the medication. The heart kind of stops beating for a second. You can see that on the EKG. Then it starts back up and has hopefully converted back to a regular rhythm. 

    Side effects: if the rhythm is worsening, if the patient's blood pressure drops, shortness of breath, facial flushing, chest pain, tingling. 

    Contraindicated: bronchospasms, asthma, bronchitis, bradycardia, severe hypotension, sick sinus syndrome. (Alliteration! He he.)
  2. Amiodarone
    This is used in V tach, V fib, and A fib with RVR. It vasodilates and prolongs the refractory period by interacting with potassium, sodium, and calcium channels. Amioderone is fat soluble, so it is better absorbed if the patient takes the medication orally with food. If given intravenously for cardiac arrests the dose is typically 300 mg in 30 mL of NS. If it's a loading dose and given intravenously it's typically 150 mg in 100 D5W over 10 minutes. Again, this can vary from hospitals/doctors, and I'm just trying to give you an idea. This can be used in life-threatening events, or also to suppress chronic arrhythmias. 

    Monitor the patient's heart monitor closely for any changes in their rhythm. It can cause bradycardia, torsades, or a new onset of v tach or v fib. Monitor lab values for electrolytes, AST, ALT. Teach the patient the importance of taking this drug consistently (if it's being ordered for chronic conditions. Obvi.) Amiodarone inhibits the CYP 450 isozyme. (Just like that disgusting grape fruit.) That interacts with the clearance of many medications. So beware if your patient is on digoxin, warfarin, cyclosporin, simvastatin, procainamide... basically everything. Call pharmacy or the physician. 

    Side effects: hypotension, anaphylaxis, heart failure, cardiogenic shock, decreased potassium, decreased magnesium, nausea, liver injury. 

    Contraindications: iodine allergy, cardiogenic shock, bradycardia, use with caution with liver dysfunction. Client shouldn't be breastfeeding.

    This is the one drug on this post that I give the most. One of the things I wished I had known sooner was that when we give multiple boluses to patients and then start to load them on oral pills-- by that time the patient has ingested a lot of amio and is usually very nauseated. The patients that I take care of now go into afib with RVR a lot so I give a lot of boluses.
  3. Atropine
    This is given to treat bradycardia. This drug is created using parts from the plants nightshade and mandrake.... my inner geek really likes those plants for some reason... nightshade... it always seemed so very Poison Ivy from the Batman comics... ANYWAYS...

    Atropine not only increases heart rate, it can also dilate the pupils, and can reduce secretions. So in the ICU you might be giving this drug to treat bradycardia. You might also give this drug when someone is in the final stages of their life, to decrease secretions and allow for a more peaceful passing.

    Likewise, by blocking acetylcholine at the muscarinic receptors, it can help treat poisonings of nerve gasses and insecticides. So this is used by our troops (Thank you for your service!!) in areas deemed as high targets for chemical warfare. Not that most of us would ever encounter that-- I just like to know little factoids about our men in uniform.

    To treat bradycardia intravenously, anticipate giving 0.5 mg. This can be repeated every 3-5 minutes, but not to exceed 3 mg total.

    Side effects: tachycardia, dry mouth, blurred vision, dilated pupils, tremor, nausea, vomiting, urinary retention.

    Contraindications: in patients with narrow angle glaucoma.
  4. Epinephrine
    Is a potent catecholamine that increases heart rate, raises blood pressure, increases contractility and automaticity. This is used when the patient is in asystole, bradycardia, or has V tach/V fib that is unresponsive to defibrillation. You might also administer this when there is severe hypotension, anaphylactic shock, or bronchospasms.

    For cardiac arrest expect to give 1 mg every 3-5 minutes mixed in 10 mL saline flush. For anaphylactic treatment expect to give 0.1-0.25 mg. (Again, this is a guideline just so you have an idea what a typical order looks like. Follow the order from the physician.)

    Monitor the patient's blood pressure and respirations closely. Monitor their intake and output because it can cause renal ischemia. Make sure the patient is on a heart monitor and watch for any changes in rhythm. Monitor the insertion site of the IV. Patient shouldn't breastfeed.

    Side effects: increased BP, N/V,  anxiety, ventricular arrhythmias, stroke, tissue necrosis if the line infiltrates.

    Contraindicated: in cardiogenic or hemorrhagic shock, aortic aneurysm, narrow angle glaucoma.
  5. Lidocaine
    Ok, this can be used in the dentist office as anesthetic but in the ICU it's being used to treat arrhythmias. So I'm going to talk about it in that context. Cool? Cool. 

    It is used in cardiac arrest to treat V fib or V tach. It can be used as an alternative to Amioderone. It is not effective against atrial arrhythmias. 

    For cardiac arrest anticipate an order to be 1-1.5 mg/kg over 2-3 minutes. Additional doses can be given in 5-10 minutes to a total of 3 mg/kg. 

    Side effects: decreased blood pressure, respiratory depression, bradycardia, toxicity (CNS depression and can lead to a seizure- can occur in infusions greater than 24 hours- so monitor blood levels of lidocaine- Therapeutic range is 1.5- 5 mcg/mL .)

    Monitor the patient's blood pressure and respirations. Observe the patient's heart monitor for any changes either bradycardia or if another dysrrhythmia occurs. Again, monitor blood levels if it's a long infusion. Toxicity symptoms may include ringing ears, tremors, seizures, N/V, twitching, confusion, blurred vision. 

    Contraindicated: Heart block, AV block, bradycardia, low cardiac output, heart failure, liver disease.
  6. Procainamide
    Is an antiarrythmic that increases the refractory period of the atria and reduces impulse conduction. This is used to treat life threatening sustained V tach. It has some serious side effects so it shouldn't be used to treat arrhythmias that are of a lesser threat.

    It's a slim line between therapeutic and toxicity so that's another reason why it should be used with great caution. Therapeutic levels are 4-8 mcg/ml and toxicity can occur at 8-16 mcg/ml. So, there's a pretty tight line. Signs of toxicity may include: dizziness, confusions, N/V, decreased urinary output, tachycardia.

    Monitor the patient's BP, heart rate, EKG, and check lab levels for toxicity, liver or renal failure. The EKG may start to show a widening of the QRS complex, or a lengthening of the PR and QT intervals. Observe the heart monitor for other dysrrhythmias such as V Tach, V fib, asystole, PVCs.

    Side effects: hypotension, widening QRS, dsyrrhythmias, toxicity, and prolonged use can lead to lupus-erythematosus-like syndrome.

    Contraindicated: Complete heart block, prolonged QT interval, torsades, and use in caution wiht HF patients; digoxen toxicity; and hypokalemia.
  7. Sotalol
    Is a beta blocker that treats symptomatic A fib, A flutter, V fib or V tach. It's advised to only be used to treat serious threatening arrhythmias because it has the potential to produce a prolonged QT interval that then could turn into torsade de pointes (rare, but it could possibly happen). So before this is used as an option to treat the patient's arrhythmia you should see if the valsalva maneuver can convert the rhythm.

    Side effects: dizziness, fatigue, headache, weakness, nausea, bradycardia, shortness of breath, constipation.

    Contraindications: Asthma, cardiogenic shock, pulmonary edema, 2nd or 3rd degree heart block.
  8. Vasopressin
    A synthetic analog of ADH. So it increases the reabsorption of water. It can be used to treat diabetes insipidus. It can also be used to treat asystole or pulseless V fib/V tach as an alternative to epinephrine. It's also used in the ICU to support the blood pressure of a patient that might be a potential organ donor. It has an off label use for treating variceal bleeding as well.

    For cardiac arrest its typically a 40 unit IVP. For DI it's 5-10 units injected 2-4 times a day. For maintaining blood pressure it's determined by the patient's response.

    So as the nurse you want to pay close attention to the patient's blood pressure, their heart monitor for any changes in rhythms. If the patient is being treated for Diabetes Insipidus you'll want to monitor their intake and output closely, as well as their lab work-- electrolytes, BUN, creatinine, BUN:Creatinine ratio. Assess for signs of dehydration and fluid volume overload.

    Side effects: Anaphylaxis, tremor, sweating, N/V, heart block, decreased cardiac output, hypertension, angina, intestinal cramps, bronchoconstriction, water intoxication-- administration of norepinephrine may exaggerate effects.

    Contraindications: Chronic renal failure. Use cautiously with CHF, seizures, migraines, asthma, renal impairment.


Wow! That was a lot of information to process. Go eat yourself a cookie... haha. Thank you, Peter, for the comment asking for this post. I am always happy to oblige.

So, you may have noticed I've been on a bit of a hiatus. My apologies. It's been insanely busy. Since my last post; I presented my thesis, defended my poster, got inducted into some cool nursing societies, I GRADUATED. Whoo hoo!! And I already have my diploma so they can't take it back. Ha! I passed the Clinical Nurse Leader exam. Yay. And I passed NCLEX in only 75 questions!! Holy sweet baby jesus. Thank you. Now I have a lot of fancy letters after my name.

I am in the process of starting a new job- with transplants. I couldn't stay away. I took a break today in packing up my ridiculously overflowing apartment to write this post. I need to have a yard sale. I'm a hoarder. I can't help it. I just develop such irrational bonds with old notebooks that  I'll never look at ever again... Just being honest. I don't need my old chemistry notes from 11th grade. Throwing out books just feels so wrong! I've tried to resell some of them so that's made me some extra cash. Too bad they're all ugly and I can't use them as cute decorations. I have over 75 cookbooks.... I may have a problem....

There's just a lot happening right now in my personal life. But for those of you still checking in on this site- THANK YOU!! I'm going to try to get back into the swing of things soon. I really enjoy this process.

Leave me a comment if there is anything you're dying to see me post about!! 

Post apocalyptic zombie baseball? Done and done.




  1. Replies
    1. Not a problem. Thanks for reading! Good luck to you in your nursing endeavors. Let us know if we can be of any more help. :)

  2. it's me kamal shrish. thank you so much nightingale, for making ICU management so much easier by listing the name of drugs. these drugs uses are vital. and your website being a constant source of enthusiasm for the academic project and true educators of clinical knowledge . lastly and most importantly i would like to thank you again.

    1. Aww thank you!! This is just what I needed to see today. :) I've started a new job and I've been neglecting the blog. {Sorry everyone!!} But I am so happy that this information was helpful for you. Thank you for your kind words and for reading! Happy nursing! :)

  3. In my ten plus years of ER nursing I have never seen a Dr. push Adenosine or any other drug. We give it 6mg then 12 mg then move on.... no second dose of 12 anymore... go to the cardioversion.
    Thanks for the information...Good education!

    1. Hi Marky! Sorry, just saw the comment. Oops. I'd say the ED kind of has exceptions. I've seen Adenosine pushed a couple times in an ICU setting. A doctor has always been present, sometimes the doctor pushes the drug and sometimes the nurse pushes it. Only one of the times that I've witnessed did it get pushed three times, 6mg, 12mg and 12mg. That patient was a large fella, so that may be why it took so much medicine to take effect. I'm sure hospitals vary in their policies and the ED has emergent situations that may warrant the presence of a doctor making them unavailable during the administration of the adenosine. My hats off to you. The ER scares me. Thanks for reading and Happy Thanksgiving!! :)

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