Titration of Nitroglycerin IV
On the ED CHF standing orders, we have an option of using
nitroglycerin paste or IV. Nitroglycerin
(NTG) is usually started at a dose of 10mcg/min. The drug is
then titrated every 5 minutes by 10mcg/min.
The goal for NTG is to titrate until you get a 20% drop in mean arterial
pressure (MAP) from baseline. The MAP is
the average arterial pressure during a cardiac cycle. It represents the perfusion pressure for the
blood flow through the cardiovascular system.
The MAP
is the number in parentheses on the monitor after the blood pressure. You can also calculate the MAP by the
following equation:
(systolic
pressure) + (diastolic pressure X 2)
MAP = __________________________________
3
To figure a 20% decrease in MAP:
MAP X 0.80 = goal MAP
The goal
is to titrate NTG to that goal MAP and maintain it at that level. If you drop below that number, then you would
decrease the drip rate.
If you
are using Nitroglycerin for indications other than CHF make sure you are aware
of what the titration parameters are such as relief of chest pain or systolic
blood pressure. The maximum dose on our
pumps is set at 200mcg/min. Always make
sure that Nitroglycerin tubing is used.
Several Drugs Withdrawn From the Market…
Zelnorm
The irritable bowel syndrome drug
Zelnorm was voluntarily taken off the market because of possible cardiovascular
risks. A new safety analysis found a
higher chance of heart attack,
stroke, and worsening chest pain.
Pergolide
The
company that manufactures and distributes Pergolide (dopamine agonist used for
the treatment of Parkinson’s) decided to withdraw the drug from the market due
to the potential for heart valve damage. Two new studies (published in The New England Journal of Medicine in
January 2007) showed that patients with Parkinson’s disease who were treated
with Pergolide (Permax) had an increased chance of serious damage to their
heart valves when compared to patients who did not receive the drug.
Tigan suppository
The FDA has ordered companies to stop
manufacturing and distributing unapproved suppository drug products containing
trimethobenzamide (Tigan) used to treat nausea and vomiting in adults and
children. The reason for the withdrawal is due to the lack of evidence of
effectiveness of the suppository form. The oral and injectable products are still available.
CMC Drug
Error Report …
Some examples of errors or near
misses that have been reported by you:
ü
Insulin given
IM instead of IV
ü
Antibiotic
orders missed (7 hour delay)
ü
MAP not
calculated correct for Nitroglycerin drip
ü
Order for Nafcillin
1.5gm, pharmacy dispensed 1g instead
ü
Urine sample
mislabeled with wrong patient (chart was in wrong slot)
Please continue to report any error(s) you
encounter or make, or any near miss.
Remember this is completely anonymous.
Just A Reminder…
Antibiotics that are part of the pneumonia protocol are
all stocked in the omnicell.
Biaxin (clarithromycin) 250mg tablets
Erythromycin 500mg vials
Rocephin 1g vials and premixed bags
Avelox 400mg IV premixed bag
Cipro 400mg IV premixed bag
Clindamycin 600mg IV premixed bag
Zosyn 3.375g IV premixed bag
Doxycycline 100mg vials
April
4/2 Christine Kulstad, Brad Kurtyka,
Evon Niezabitowski, Joanne Chocola
4/3 Yolanda Woods
4/5 Omar Sawlani
4/8 April Bisaga, Pam Colangelo
4/9 Evelyn Haynes
4/10 Barbara Zwicki
4/11 Amy Hansen, Laura Pratt
4/14 Salimah Muhammad
4/16 Robert Harwood, Angelina Larks,
Sheryl Anderson
4/17 David Nash, Sally Heinzel
4/19 Helen Izzo, Mary Kowalewski
4/20 Megan McGuffage, Tammy Kristensen
4/22 Ejaaz Kalimullah
4/23 Karen Hunhoff
4/25 Donna Martin
4/26 Cara McGuire, Kate Murczek
4/27 Cheryl Hickey, Jolene Lorenz
4/28 Staci Sienkiewicz
4/29 Mary Kay Griffin
4/30 Melissa DiDomenico, Cindy Markunas
Erik Kulstad, MD – Top Peer Reviewer for
Annals of Emergency Medicine
Welcome: Jim
Jensen, PharmD (3-11)
Please forward any news or announcements via email or
IBEX to Rolla Sweis.
Any questions or comments please
send to:
Andrea Carlson, MD
acarlsonmd@comcast.net
rogu@alum.mit.edu
Rolla Sweis, PharmD
Rolla.Sweis@advocatehealth.com