Term
Vasopressor and Vasodilators |
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Definition
• Norepinephrine (Levophed) • Phenylephrine (Neo-synephrine) • Dopamine (Intropin) • Dobutamine (Dobutrex) • Vasopressin (Pitressin) • Nitroglycerin • Morphine • Sodium nitroprusside (Nipride) • Hydralazine (Apresoline) • Inamrinone (Inocor) • Milrinone (Primacor) • Digitalis (Digoxin, Lanoxin) • Furosemide (Lasix) |
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Term
Norepinephrine (Levophed) |
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Definition
Mechanism of Action
Vasopressor & Sympathomimetic Endogenous catecholamine • Potent alpha-adrenergic receptor stimulation • Increases myocardial contractility due to weaker beta-1 effects • Arterial and venous vasoconstriction from potent alpha stimulation • Increased SVR (afterload) increases blood pressure and may diminish cardiac output. • Due to an increase in myocardial oxygen demand, may worsen myocardial ischemia, especially if coronary vasoconstriction is induced by coronary alpha receptor stimulation. |
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Term
Norepinephrine (Levophed) |
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Definition
Indications to Administer
• Hemodynamically significant hypotension refractory to other sympathomimetics • Cardiogenic shock • Used more often with low SVR states (e.g., sepsis) than in MI-related hypotension |
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Term
Norepinephrine (Levophed) |
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Definition
Contraindications
• Hypotension due to hypovolemia (may be used as a temporary agent until volume can be replaced) • Profound hypoxemia or hypercarbia • Mesenteric or peripheral vascular thrombosis • Pre-existing hypertension • Use with caution in patients with heart disease and/or hyperthyroidism. |
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Term
Norepinephrine (Levophed) |
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Definition
Side Effects
• Hypertension • Arrhythmias (baroreceptor-mediated bradycardia) • Chest pain • Decreased peripheral perfusion • Decreased renal perfusion (monitor urinary output and renal function) |
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Term
Norepinephrine (Levophed) |
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Definition
Dose
• Start at 0.5 - 1.0 mcg/min • Titrate to desired effect (SBP of 90 - 100 mmHg); up to 30 mcg/min • Adult dosage commonly 2 - 12 mcg/min • Mix 4 ml ampule (1 mg/ml) in 500 ml D5W or 0.9% NSS to make 8 mcg/ml |
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Term
Phenylephrine (Neo-synephrine) |
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Definition
Mechanisms of Action
• Potent direct-acting sympathomimetic (synthetic) with strong alpha-adrenergic and weak beta-adrenergic cardiac stimulant properties • Elevates systolic and diastolic pressures due to peripheral arteriolar constriction. • Constricts capacitance vessels and increases venous return. • Cardiac output is slightly decreased due to the increase in afterload. • Coronary blood flow is increased. • Rise in blood pressure may cause reflex bradycardia due to aortic baroreceptor stimulation. • Produces little or no CNS stimulation |
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Term
Phenylephrine (Neo-synephrine) |
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Definition
Indications
• Hypotension from shock, shock-like states, or drug- induced shock • To overcome PSVT • During anesthesia to maintain adequate level of blood pressure and prolong anesthesia drug’s effects |
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Term
Phenylephrine (Neo-synephrine) |
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Definition
Contraindications
• Severe coronary disease or hypertension • Hypotension due to hypovolemia • Ventricular tachycardia • Cautious use in thyroid dysfunction, diabetes mellitus, myocardial disease, bradycardia, or cerebral atherosclerosis |
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Term
Phenylephrine (Neo-synephrine) |
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Definition
Adverse Reactions
• Sympathomimetic effects: palpitations, tachycardia, rebound bradycardia (especially in overdoses), extrasystoles, ventricular irritability, hypertension • Tremors, dizziness, sleeplessness, headache, excitability • Severe visceral or peripheral vasoconstriction and tissue necrosis if IV infiltrates |
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Term
Phenylephrine (Neo-synephrine) |
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Definition
Dose
• Titrate 0.1 - 0.18 mg/min until BP stabilizes, then 0.04 - 0.06 mg/min for maintenance infusion. • Dilute 10 mg in 500 ml D5W or 0.9% NSS to make 0.2 mg/ml concentration. |
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Term
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Definition
Mechanisms of Action
VASOPRESSOR • Chemical precursor of norepinephrine • Low doses = dopaminergic receptor stimulation • Vasodilation of renal, mesenteric, and cerebral arteries • Urine output increased, while heart rate and blood pressure are usually unchanged • Mid-range doses = beta-1 adrenergic receptor stimulation with weak alpha-stimulation • Increased cardiac output due to increased heart rate and contractility • Small increase in SVR • Weaker alpha-1 at this dose antagonized by beta-1 stimulation • High doses = alpha-adrenergic receptor stimulation • Renal, mesenteric, and peripheral vasoconstriction • Increase in SVR and preload • Doses above 20 mcg/kg/min produce alpha stimulation similar to norepinephrine • Increases myocardial work without compensatory increase in coronary blood flow |
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Term
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Definition
Indications
• Cardiogenic shock • Hemodynamically significant hypotension, in absence of hypovolemia (systolic blood pressure [SBP] < 70 mmHg) • CHF, in combination with other agents (such as sodium nitroprusside) |
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Term
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Definition
Precautions
• Excessive vasoconstriction at high doses • Can compromise circulation to the extremities in some patients (monitor peripheral pulses, color, and temperature). • Will increase heart rate and may cause supraventricular or ventricular arrhythmias. • Increased myocardial workload without increase in coronary perfusion can cause or worsen ischemia. • Taper infusion carefully to avoid acute hypotension. • Monoamine oxidase (MAO) inhibitors may potentiate effects of dopamine. |
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Term
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Definition
Contraindications
• Cardiogenic shock • Uncorrected tachyarrhythmias • Ventricular fibrillation • Hemodynamically significant hypotension, in presence of hypovolemia (SBP < 70 mmHg) |
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Term
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Definition
Adverse Reactions
• Sympathomimetic stimulation: tachycardia, hypertension, ventricular ectopy, angina, anxiety, and decreased peripheral perfusion • Headache • Nausea and vomiting • Decrease in pulse pressure • Extravasation causes tissue necrosis and sloughing |
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Term
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Definition
Dose
• Low dose: 2 - 5 mcg/kg/min • Mid-range dose: 5 - 10 mcg/kg/min • High dose: > 10 mcg/kg/min • Titrate dosage to desired hemodynamic effect, using data from right heart catheterization as measure of effects. • Dilute 400 mg in 250 ml D5W for concentration of 1600 mcg/ml. |
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Term
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Definition
Mechanisms of Action
VASOPRESSOR • Sympathomimetic with potent inotropic effects • Stimulates beta-1 and alpha-adrenergic receptors • Minor alpha stimulation antagonized by !stronger beta-1 effects • Less likely to induce tachycardia at therapeutic doses than isoproterenol or dopamine • Increase in renal and mesenteric blood flow due to increased cardiac output • May be combined with dopamine to increase cardiac output, SVR, and preload. • Decreases pulmonary occlusive pressures and peripheral resistance • Myocardial work is balanced by increased coronary blood flow. • Does not cause release of norepinephrine |
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Term
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Definition
Indications
• Hypotension with pulmonary congestion and dysfunction (e.g., CHF, cardiogenic shock) • Hemodynamically significant hypotension (SBP of 70 - 100 mmHg) • Drug of choice in low cardiac output states due to RV infarction • Stress test echocardiography |
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Term
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Definition
Precautions
• Monitor for arrhythmias and fluctuations in blood pressure • Insulin effects may be antagonized due to beta-2 stimulation in the pancreas • Extravasation leads to tissue necrosis • Cavity obliteration during dobutamine stress echocardiography (DSE) • Due to myocardial thickening and increased contractility • walls may “touch” with resultant decrease in heart rate and cardiac output • May be alleviated by increasing preload (volume infusion) |
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Term
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Definition
Contraindications
• Idiopathic hypertrophic subaortic stenosis (IHSS) • LVOT obstructions • Tachydysrhythmias • Pre-existing hypertension • Shock due to hypovolemia • Acute coronary syndrome with ventricular irritability • Hypersensitivity to sympathomimetic amines |
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Term
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Definition
Adverse Reactions
• Tachycardia, arrhythmias, ventricular ectopy, palpitation, hypertension • Anginal pain • Peripheral vasoconstriction (may be countered with combined sodium nitroprusside infusion) • Shortness of breath • Nausea and vomiting • Headache • Anxiety, jitteriness |
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Term
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Definition
Dose
• Start at 0.5 mcg/kg/min IV and titrate to desired effect • Usual dose is 2 - 20 mcg/kg/min • Insertion of Swan-Ganz catheter for continuous pressure monitoring • Titrate upward so as not to increase heart rate by greater than 10% (unless for stress echocardiogram). • Dilute 1000 mg in 250 ml of D5W or 0.9% NSS for a concentration of 4 mg/ml. |
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Term
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Definition
Mechanisms of Action
ANTIDIURETIC & HEMOSTATIC• Anti-diuretic hormone • Increases permeability of the renal tubular epithelium to adenosine monophosphate and water, promoting reabsorption of water and producing concentrated urine • Cardiovascular effects related to potent alpha-adrenergic stimulation of vascular smooth muscles, leading to vasoconstriction and increased afterload • Beneficial redistribution to coronary and cerebral vasculature without beta-1 induced increase in myocardial oxygen demand seen with epinephrine (cardiac arrest benefits) |
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Term
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Definition
Indications
• Cardiac arrest due to ventricular arrhythmias, asystole, or PEA (alternate to epinephrine) • Hemodynamic support in vasodilatory shock (e.g. septic shock) refractory to more traditional therapy • Esophageal variceal hemorrhage |
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Term
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Definition
Precautions
• Several drug interactions; consult drug reference or pharmacist (except in cardiac arrest) • May provoke cardiac ischemia and angina • Monitor for hypersensitivity reactions (urticaria, bronchoconstriction, angioedema, anaphylaxis). |
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Term
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Definition
Contraindications
• None during cardiac arrest • Ischemic coronary artery disease or advanced arteriosclerosis • Renal failure |
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Term
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Definition
Adverse Reactions
• Tremor, headache, vertigo • Vasoconstriction with reduced peripheral perfusion • Hypertension • Arrhythmias, decreased cardiac output, myocardial ischemia • Anginal chest pain • Bronchoconstriction, respiratory congestion • Abdominal cramps, nausea and vomiting, flatulence |
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Term
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Definition
Dose
• Cardiac arrest: single bolus of 40 units IV; use epinephrine if no response in 10 - 20 minutes • Currently acceptable via endotracheal route; no set dosage as of current ACLS guidelines |
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Term
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Definition
Mechanism of Action
• Antianginal & Vasodilator • Nitrate smooth muscle relaxant • Relieves angina via vasodilation of the venous system, which reduces venous return to the heart • Causes a decrease in preload (ventricular volume, pressure, and wall stress); this decreases ventricular contractility and myocardial oxygen demand • Dilates collateral circulation, including venous capacitance • Dilates large coronary arteries and increases collateral blood flow to ischemic myocardial tissue • Blocks vasospasm at the site of plaque rupture and increases collateral blood flow to ischemic myocardial tissues • Sublingually, nitroglycerin decreases filling pressures without lowering SVR • Cardiac output usually falls due to the decrease in preload • When compared with sodium nitroprusside, nitroglycerin produces greater reduction in preload (venous return) and less reduction in afterload (arteriolar resistance) |
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Term
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Definition
Precautions
• Patient must be seated or supine when administering nitroglycerin (especially sublingual doses). • Continuous infusion should be via pump only and using appropriate tubing. • When applying or removing ointment or paste, wear gloves to avoid accidental exposure. |
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Term
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Definition
Contraindications
• Hypersensitivity to nitrate and nitrites • Hypotension (SBP < 90 mmHg; cautious use in postural hypotension) • Uncorrected hypovolemia • Severe anemia • Closed-angle glaucoma • Intracranial bleeding or head trauma • Cardiac tamponade • Constrictive pericarditis • Sildenafil or other phosphodiesterase-5 (PDE-5) inhibitor use within the preceding 48 hours • Use with extreme caution in patients with inferior wall MI (likelihood of concomitant right ventricular infarction which requires maintenance of preload). |
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Term
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Definition
Indications
• Drug of choice for acute angina pectoris attacks that are exertional or typical in nature (sublingual route) • Unstable angina • Prinzmetal’s angina (either acutely or to relieve spasm induced during ergonovine studies) • Acute myocardial infarction • Congestive heart failure (lowers SVR and increases venous capacitance) • Cardiogenic pulmonary edema • Maintenance for chest pain prophylaxis (transdermal ointment) |
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Term
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Definition
Adverse Reactions
• Headache (most common side effect; treat with aspirin or Tylenol) • Hypotension (most severe side effect; treat with trendelenberg position and IV fluid bolus) • Methemoglobinemia • Change in hemoglobin configuration from • Fe2+ to Fe3+ state • Can result in refractory hypoxemia; usually related to high doses or longterm use • Treated with methylene blue infusion • Bradycardia (hypotension and bradycardia usually respond to IV fluids or atropine) • Baroreceptor-mediated tachycardia, palpitations • Nausea and vomiting • Syncope or collapse |
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Term
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Definition
Dose
Sublingually (SL): • 0.3 - 0.4 mg tablet or metered spray every 5 minutes x 3 doses • SL nitroglycerine (NTG) is drug of choice in angina or MI • Evaluate pain scale and blood pressure before first dose and after each dose • If sublingual NTG fails to relieve pain after three doses, patient should seek medical care ASAP. • Intravenously: • Start at 10 - 20 mcg/min and titrate until desired effect (pain free) is noted or to a maximum of 500 mcg/min. • Bolus with 12.5 - 25.0 mcg, then start infusion • Best for patients with unstable angina or for continuous treatment for AMI • Dilute 40 mg with 250 ml D5W or 0.9% NSS for a concentration of 160 mcg/ml. • Transdermal ointment: • For chronic therapy, not for acute treatment of chest pain • 1 - 2 inches of 2% paste applied to the chest wall |
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Term
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Definition
Mechanisms of Action
•Narcotic analgesic (Opiate)
• Schedule II narcotic (opioid) agonist analgesic and vasodilator derived from the opium poppy • Naturally occurring narcotic analgesic • Analgesic effects due to binding at various receptor sites, mimicking the effects of endogenous endorphins and enkephalins • μ1: main action of this receptor is analgesia • μ2: euphoria, respiratory depression, bradycardia, physical dependence, and ileus are elicited at this receptor • Delta: modulates activity of mu receptors; it is thought that mu and delta receptors coexist as a complex • Increases venous capacitance, reduces venous return, and decreases preload • Decreases pulmonary congestion • Reduces pulmonary capillary occlusive pressure • Facilitates reabsorption of pulmonary edema from the alveoli to the vasculature • Vasodilation decreases SVR at the arteriolar level and increases stroke volume, cardiac output, and decreases myocardial oxygen demand. |
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Term
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Definition
Indications
• Moderate to severe pain • Pain and anxiety relief during acute MI • Acute cardiogenic pulmonary edema (congestive heart failure) |
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Term
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Definition
Precautions
• Action is potentiated when used in combination with sedatives, hypnotics, or barbiturates. • Narcotic effects can be reversed by naloxone. • Encourage deep breathing, coughing, and frequent changes in position to minimize the risk of atelectasis |
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Term
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Definition
Contraindications
• Hypersensitivity to the drug • Decreased level of consciousness • Increased intracranial pressure or head trauma • Convulsive disorders • Hypotension • COPD • Chemical-irritant induced pulmonary edema (e.g., chlorine, ammonia) • Ingested poisonings • Chronic alcoholism • Undiagnosed intra-abdominal or intracranial conditions • Patients taking MAO inhibitors |
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Term
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Definition
Adverse Reactions
• Respiratory depression • Hypotension (especially in patients with hypovolemia or increased SVR) • Dose-dependent bradycardia due to vagal stimulation; may be blocked or reversed by use of an anticholinergic (such as atropine) • Depression of cough reflex and respiratory status may induce atelectasis. • Constipation and urinary retention • Nausea and vomiting • Hypothermia • Localized allergic reaction with IV administration • Addiction with long-term use • High doses or overdose may cause: • Anaphylaxis • Cheyne-Stokes respiration or apnea • Severe myocardial depression • Tachycardia • Death |
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Term
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Definition
Dose
•Dosage varies with patient’s size, age, and renal function. • Start with 2 - 10 mg slow IV over 3-5 minutes. • Titrate in small increments (1 - 3 mg) to desired effect, while maintaining adequate respiratory status. |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Mechanisms of Action
• Vasodilator • Anti-hypertensive
• Potent peripheral vasodilator, which affects arteriolar and venous smooth muscles (primarily arteriolar) • Effects are seen immediately and resolve within minutes of infusion cessation • Reduces blood pressure: • Decreases SVR (afterload) • Increases venous capacitance (preload) • Increases cardiac output and enhances systolic emptying |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Indications
• Hypertensive emergencies (drug of choice) • Hypertensive emergency associated with neurologic dysfunction • Treatment of failure (by decreasing preload and afterload, thus myocardial workload) • Heart failure with pulmonary congestion refractory to diuretics • Combined with dopamine to produce hemodynamic effects similar to dobutamine |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Precautions
• Protect from light with foil and use immediately after mixing. • Hemodynamic monitoring (arterial and right heart lines) is essential. • Imbalance between coronary supply and demand may induce or worsen myocardial ischemia. • Possible coronary “steal” • May cause right-to-left shunt in presence of atrial septal defect (ASD) or ventricular septal defect (VSD), leading to hypoxia and cyanosis • Sodium thiocyanate toxicity • Metabolite from liver • Most likely if used for over 72 hours • Monitor patient for altered mental status • Medication should be a faint yellow, not brown • Long-term use may cause methemoglobinemia with resultant refractory hypoxemia. • Prolonged use may cause hypothyroidism • Reduce doses in the elderly • Monitor arterial pressure and central venous pressure (CVP) |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Contraindications
• Treatment of compensatory hypertension (A-V shunt or coarctation of the aorta) • Known inadequate cerebral perfusion • Use cautiously in renal or hepatic dysfunction |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Adverse Reactions
• Usually occurs due to too rapid rate of infusion – reversible • Hypotension (most common side effect; may induce or exacerbate ischemia) • Nausea and vomiting • Diaphoresis • Headache • Restlessness and apprehension • Muscle twitching • Palpitations • Chest or abdominal pain |
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Term
Sodium nitroprusside (Nipride) |
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Definition
Dose
• Start infusion at 0.5 mcg/kg/min and titrate every 5 - 10 minutes to desired effect (SBP < 150 mmHg and/or DBP < 60 - 90 mmHg). • Normal range is 0.5 - 8.0 mcg/kg/min. • Mix 50 mg with 2 - 3 ml of D5W in the vial, then add 250 ml of D5W for a concentration of 200 mcg/ml. |
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Term
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Definition
Mechanisms of Action
Class: • Anti-hypertensive • Direct vasodilator
• Non-nitrate vasodilator and antihypertensive • Reduces blood pressure mainly by direct effects on vascular smooth muscles of the arterioles, resulting in vasodilation • Little effect on venous-capacitance vessels • Diastolic response often greater than systolic • Vasodilation reduces afterload and substantially improves cardiac output, as well as renal and cerebral perfusion. • Hypotensive effect may be limited by sympathetic reflexes (increases in heart rate, stroke volume, and cardiac output). |
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Term
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Definition
Indications
• Moderate to severe hypertension, including acute hypertensive emergency • Pregnancy-induced hypertension and preeclampsia • May be used in conjunction with cardiac glycosides or other vasodilators in short-term treatment of CHF • Unexplained pulmonary hypertension |
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Term
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Definition
Precautions
• Taper drug slowly to avoid sudden possible rise in blood pressure. • Blood dyscrasia resulting in decrease in hemoglobin and hematocrit • Obtain baseline and periodic BUN, creatinine, uric acid, serum potassium, blood glucose, and CBC; also obtain ECG. • Use with caution if used concomitantly with beta-adrenergic blockers. • Tartrazine may be contained in some products; may cause allergic-type reaction in patients who also have aspirin hypersensitivity. |
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Term
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Definition
Contraindications
• Coronary artery disease or MI • Pre-existing hypotension • Persistent tachycardia • Advanced renal impairment • Mitral valve disease |
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Term
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Definition
Adverse Reactions
• Headache and dizziness • Palpitations and tachycardia • Drug-induced hypotension • Angina • Nausea and vomiting, diarrhea, anorexia • Decreased hematocrit and hemoglobin levels • Hypersensitivity reactions: rash, urticaria, fever, chills, arthralgia, hepatitis, eosinophilia |
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Term
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Definition
Dose
• Hypertension in adults: • : 10 - 50 mg QID • Intravenous: 5 - 40 mg slow IV push over 1 - 2 minutes, may repeat every 4 - 6 hours as needed • Hypertension in geriatrics: start with 10 mg PO BID or TID and titrate as needed |
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Term
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Definition
Mechanisms of Action
Class : •Inotrophic agent
• Phosphodiesterase (PDE) inhibitor; noncatecholamine inotropic agent • Formerly called amrinone • Inhibits peak III cyclic AMP isoenzyme in cardiac and vascular muscle, resulting in direct inotropic effect and direct arterial vasodilation; effects are linked to inhibition of phosphodiesterase • Drug acts slightly different than digitalis and beta- adrenergic stimulants. • Rapid acting, potent inotropic (enhanced contractility) and vasodilator • Cardiac output increases and SVR and preload decrease at dosages of 2 - 15 mcg/kg/min. • Higher doses produce tachycardia. • Hemodynamic effects are similar to dobutamine. |
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Term
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Definition
Indications
• Severe CHF refractory to diuretics, vasodilators, and conventional inotropic agents • Additive to digitalis and catecholamine therapy • Promotion of hemodynamic improvements in patients with CHF from ischemic heart disease |
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Term
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Definition
Precautions
• Clear yellow in appearance • Store at room temperature and protect from light. • May increase or induce myocardial ischemia • Do not mix with furosemide or dextrose containing solutions. • Adjust dosage frequently to achieve desired effect at the lowest possible dosage. |
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Term
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Definition
Contra- indications
• Hypersensitivity to inamrinone or bisulfites • Pre-existing hypotension • Presence of uncorrected aortic or pulmonic valve obstruction • Right ventricular outflow tract (RVOT) or left ventricular outflow tract (LVOT) obstruction (IHSS) • Patients with uncorrected hypokalemia or dehydration |
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Term
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Definition
Adverse Reactions
• Nausea and vomiting • Thrombocytopenia due to hepatotoxicity (monitor platelet count daily) • Dose-dependent tachydysrhythmias, ventricular irritability, hypotension • Muscular stiffness, myalgias, tenderness, and localized inflammatory reaction at site of infusion • Hypersensitivity reaction (itching) may occur with long-term use • Fever |
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Term
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Definition
Dose
• Loading dose: 0.75 mcg/kg over 2-5 minutes • Infusion at 5 - 10 mcg/kg/min, titrated to desired effect • Adjust frequently to achieve optimal effects at lowest possible dose • Mix 20 ml ampule of 100 mg (5 mg/ml) with 0.9% NSS for 1 - 3 mg/ml concentration |
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Term
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Definition
Mechanisms of Action
Class: •Inotropic agent
• Phosphodiesterase (PDE) inhibitor; noncatecholamine inotropic agent • Positive inotropic effect by increasing cellular levels of cAMP (inhibits peak III cyclic AMP isoenzyme in cardiac and vascular muscle) • Results in direct inotropic effect (increased contractility) and vasodilation with little effect on chronotropic activity • Vasodilation via direct relaxation of vascular smooth muscles with resultant reduction in afterload • Overall improvement in myocardial contractility, ejection fraction, and cardiac output |
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Term
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Definition
Indications
• Short-term treatment of CHF refractory to diuretics or digitalis • To increase cardiac output and to reduce pulmonary capillary wedge pressure (PCWP) and SVR without increasing myocardial oxygen demand • Chronic heart failure with decompensation |
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Term
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Definition
Precautions
• Use cautiously in patients with atrial flutter or fibrillation due to shortening of AV nodal conduction time and potential for increased ventricular response. • Avoid infusion in same IV line as furosemide (produces a precipitate). • Monitor vital signs, cardiac monitor, I&O’s, renal function, and platelet levels. • Expect dose reduction as cardiac output and urinary output improve. |
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Term
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Definition
Contraindications
• Hypersensitivity to the drug • Severe aortic and pulmonary valvular stenosis • Hypertrophic cardiomyopathy • Acute MI (initial phase) • Hypotension |
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Term
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Definition
Adverse Reactions
• Headache • Ventricular ectopy, ventricular tachycardia (sustained or non-sustained), ventricular fibrillation • Hypotension • Chest pain and cardiac ischemia • Thrombocytopenia (long-term therapy necessitates daily monitoring of platelet count) • Local tissue discomfort and necrosis |
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Term
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Definition
Dose
• Initial loading dose: 50 mcg/kg slow IVP over 10 minutes • Continuous infusion: 0.375 - 0.75 mcg/kg/min • Titrate dosage to maximum clinical effects (patient improvement, increase in urinary output, improvement in right-heart hemodynamics) • Drug is commonly used concomitantly with digitalis and diuretics. • In patients with renal impairment, the maximum dose is 1.13 mg/kg/day. |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Mechanisms of Action
Class: Antidysrhythmic • Cardiac glycoside • Mild positive inotropic effect due to increased calcium in the sarcoplasmic reticulum, increasing contractility • Vasoconstriction of coronary and mesenteric arteries is due to increased calcium levels; increases SVR via increased vascular tone. • Since digitalis effects are caused by increased calcium concentrations, betablockers have no effects on positive inotropic activity. • Slows AV nodal conduction by lengthening the refractory period • Increases aortic root baroreceptor sensitivity • Results in reduction in heart rate due to increased arterial pressure • High doses cause increased and potentially dangerous adrenergic activity (binds to muscle as well as in the plasma). |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Indications
Effective control of ventricular response in atrial tachydysrhythmias without adversely affecting contractility • Calcium channel blockers may supplant digitalis as drug of choice for atrial fibrillation. • If the BP is high, use calcium channel blocker. • If the BP is normal or low, use digitalis. • May convert PSVT to normal sinus rhythm • Congestive heart failure |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Precautions
• Toxicity occurs in 20% of all patients • Toxicity and overdose treated with Digoxin Immune Fab (Digibind) • Hypokalemia • Hypokalemia sensitizes the myocardium to digitalis. • May alter onset and rate of positive inotropic effects • Hyperkalemia possible in massive digitalis overdose. • Causes massive coronary vasoconstriction • May induce or worsen ischemia• Electrical cardioversion can be dangerous in the presence of digitalis toxicity. • Can precipitate fatal ventricular arrhythmias • Use lowest energy levels (10 - 20 joules) • Hypercalcemia may also contribute to serious arrhythmias. • Many drug interactions • Verapamil and quinidine can double or triple serum levels of digitalis. • Beta-adrenergic blockers may increase ectopic beats with digitalis on board. • Concomitant presence of calcium chloride may increase risk of toxicity. • Interactions also with loop, thiazine, and potassium-sparing diuretics |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Contra-indication
Ventricular tachycardia or ventricular fibrillation Acute myocardial infarction High-degree AV blocks Digitalis intoxication (relative) WPW syndrome Use with extreme caution if at all |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Adverse Reactions
Increases slope of phase 4 of the action potential May induce delayed after-depolarizations in the Purkinje cells Results in ectopy Alters the ECG: Increases the PR interval Depresses the ST segment; characteristic ST segment scooped appearance Flattens or inverts T waves Shortens the QT interval • Shortens the QT interval • Slows impulse transmission through the ventricular conduction system – development of reentry arrhythmias • Wide range of cardiac arrhythmias: AV blocks, bi- directional ventricular tachycardia, paroxysmal atrial tachycardia with AV block, junctional rhythm and tachycardia, ventricular ectopy • Extracardiac side effects • Anorexia • Nausea and vomiting • Diarrhea • Fatigue • Mental status changes • Blurred vision • Yellow-green hue to visual spectrum • Presence of “haloes” around lights |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Dose
• Loading dose: 10 - 15 mcg/kg • IV effects in 5 - 30 minutes and peaks in 1.5 - 3.0 hours • Maintenancedosingdependentonbodysizeand renal function (monitor creatinine clearance) • Normal therapeutic range is 0.5 - 2.0 ng/ml. • Alsoavailableinoralpreparations(0.125,0.25, and 0.50 mg tablets) |
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Term
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Definition
Mechanisms of Action
Class: •Antihypertensive •Diuretic
• diuretic • Inhibits the reabsorption of sodium and chloride in the proximal and distal tubules and in the loop of Henle • Decreases renal vascular resistance; increases renal blood flow and urine output |
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Term
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Definition
Indications
• Edema associated with CHF, cirrhosis of the liver, and renal disease • Initiation of rapid diuresis in acute pulmonary edema • Volume overload (intrinsic or extrinsic) • Mild impairment in renal function |
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Term
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Definition
Precautions
• Observe for signs of electrolyte disturbances • Digitalis may exacerbate metabolic effects of hypokalemia. |
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Term
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Definition
Contraindications
• Anuria (not beneficial in patients with renal failure) • Hypersensitivity to sulfonamides • Chronic metabolic alkalosis or hyperkalemia • Hypotension or severe dehydration |
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Term
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Definition
Adverse Reactions
• Electrolyte depletion: hypokalemia, hyponatremia • Dehydration, hypotension • Vascular thrombosis or embolism • Hyperglycemia • Nausea, vomiting, diarrhea, cramping • Headache, vertigo, tremors • Rash, urticaria • Leukopenia, anemia |
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Term
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Definition
Dose
• Intravenous: 20 - 80 mg IV, usually in increments of 20 mg • Oral: 20 - 40 mg initially, titrated for effect |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Mechanisms of Action
Class: Antidysrhythmic • Cardiac glycoside • Mild positive inotropic effect due to increased calcium in the sarcoplasmic reticulum, increasing contractility • Vasoconstriction of coronary and mesenteric arteries is due to increased calcium levels; increases SVR via increased vascular tone. • Since digitalis effects are caused by increased calcium concentrations, betablockers have no effects on positive inotropic activity. • Slows AV nodal conduction by lengthening the refractory period • Increases aortic root baroreceptor sensitivity • Results in reduction in heart rate due to increased arterial pressure • High doses cause increased and potentially dangerous adrenergic activity (binds to muscle as well as in the plasma). |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Indications
• Effective control of ventricular response in atrial tachydysrhythmias without adversely affecting contractility • Calcium channel blockers may supplant digitalis as drug of choice for atrial fibrillation. • If the BP is high, use calcium channel blocker. • If the BP is normal or low, use digitalis. • May convert PSVT to normal sinus rhythm • Congestive heart failure |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Precautions
• Toxicity occurs in 20% of all patients • Toxicity and overdose treated with Digoxin Immune Fab (Digibind) • Hypokalemia • Hypokalemia sensitizes the myocardium to digitalis. • May alter onset and rate of positive inotropic effects • Hyperkalemia possible in massive digitalis overdose. • Causes massive coronary vasoconstriction • May induce or worsen ischemia• Electrical cardioversion can be dangerous in the presence of digitalis toxicity. • Can precipitate fatal ventricular arrhythmias • Use lowest energy levels (10 - 20 joules) • Hypercalcemia may also contribute to serious arrhythmias. • Many drug interactions • Verapamil and quinidine can double or triple serum levels of digitalis. • Beta-adrenergic blockers may increase ectopic beats with digitalis on board. • Concomitant presence of calcium chloride may increase risk of toxicity. • Interactions also with loop, thiazine, and potassium-sparing diuretics |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Contra-indication
Ventricular tachycardia or ventricular fibrillation Acute myocardial infarction High-degree AV blocks Digitalis intoxication (relative) WPW syndrome Use with extreme caution if at all |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Adverse Reactions
Increases slope of phase 4 of the action potential May induce delayed after-depolarizations in the Purkinje cells Results in ectopy Alters the ECG: Increases the PR interval Depresses the ST segment; characteristic ST segment scooped appearance Flattens or inverts T waves Shortens the QT interval • Shortens the QT interval • Slows impulse transmission through the ventricular conduction system – development of reentry arrhythmias • Wide range of cardiac arrhythmias: AV blocks, bi- directional ventricular tachycardia, paroxysmal atrial tachycardia with AV block, junctional rhythm and tachycardia, ventricular ectopy • Extracardiac side effects • Anorexia • Nausea and vomiting • Diarrhea • Fatigue • Mental status changes • Blurred vision • Yellow-green hue to visual spectrum • Presence of “haloes” around lights |
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Term
Digitalis (Digoxin, Lanoxin) |
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Definition
Dose
• Loading dose: 10 - 15 mcg/kg • IV effects in 5 - 30 minutes and peaks in 1.5 - 3.0 hours • Maintenancedosingdependentonbodysizeand renal function (monitor creatinine clearance) • Normal therapeutic range is 0.5 - 2.0 ng/ml. • Alsoavailableinoralpreparations(0.125,0.25, and 0.50 mg tablets) |
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