DRUGS AFFECTING BLOOD PRESSURE A.2 Anti-hypotensive Medications (3) Sympathomimetic Adrenegic Agonists/Vasopressors DOPAMINE Medication with picture Category Route Generic Name Brand Name Mechanism of Action Indications (2) Sympathomimetic Adrenegic Agonists/Vasopressors Intravenous Dopamine hydrochloride Intropin Stimulates adrenergic and dopaminergic receptors. Effects are dose dependent. Lower dosage stimulates dopaminergic receptors, causing renal vasodilation. Increases renal blood flow, urinary flow, sodium excretion. Low to moderate dosage (5–10 mcg/kg/ min): Increases myocardial contractility, stroke volume, cardiac output. High dosage (greater than 10 mcg/kg/ min): Increases peripheral resistance, vasoconstriction, B/P. Effects of DOPamine are dose dependent. Titrate to desired response. Doses greater than 20 mcg/kg/min may not have beneficial effect on BP and may increase risk of tachyarrhythmias. Contraindications Hypersensitivity to dopamine, sulphites. Pheochromocytoma, ventricular fibrillation. Uncorrected tachyarrhythmias. (2) Cautions: Ischemic heart disease, occlusive vascular disease, hypovolemia, Cardiovascular: Ventricular arrhythmia, atrial fibrillation (at very high doses), Adverse Effects ectopic beats, tachycardia, anginal pain, palpitation, cardiac conduction (2) abnormalities, widened QRS complex, bradycardia, hypotension, hypertension, vasoconstriction. Respiratory: Dyspnea Gastrointestinal: Nausea, vomiting Metabolic/nutritional: Azotemia Central nervous system: Headache, anxiety Endocrine: Piloerection Ocular: Increased intraocular pressure; dilated pupils Continuously monitor for cardiac arrhythmias. Nursing Measure urinary output frequently. If extravasation occurs, immediately infiltrate Interventions (4) affected tissue with 10–15 mL 0.9% NaCl solution containing 5–10 mg phentolamine mesylate. Monitor B/P, heart rate, respirations q15min during administration (more often if indicated). Assess cardiac output, pulmonary wedge pressure, or central venous pressure (CVP) frequently. Assess peripheral circulation (palpate pulses, note color/temperature of extremities). Immediately notify physician of decreased urinary output, cardiac arrhythmias, significant changes in B/P, heart rate, or failure to respond to increase or decrease in infusion rate, decreased peripheral circulation (cold, pale, mottled extremities). Taper dosage before discontinuing (abrupt cessation of therapy may result in marked hypotension). Be alert to excessive vasoconstriction (decreased urine output, increased heart rate, arrhythmias, disproportionate increase in diastolic B/P, decrease in pulse pressure); slow or temporarily stop infusion, notify physician. when infusion rate exceeds 20 mcg/kg/min, monitor patient for excessive vasoconstriction and loss of renal vasodilating effects. Extra (1) Keep in mind that the drugs under sympathomimetic agents usually ends with “INE” EPINEPHRINE Medication with picture Sympathomimetic Adrenegic Agonists/Vasopressors Intramuscular, Subcutaneous, Inhalation Epinephrine Adrenaline Stimulates alpha-adrenergic receptors (vasoconstriction, pressor effects), beta1adrenergic receptors (cardiac stimulation), beta2-adrenergic receptors (bronchial dilation, vasodilation). Therapeutic Effect: Relaxes smooth muscle of bronchial tree, produces cardiac stimulation, dilates skeletal muscle vasculature. Indications (2) Anaphylaxis. Hypotension Cardiac Arrest Contraindications Preexisting hypertension; occlusive vascular disease; angle-closure glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or tachycardia. When used in (2) addition to local anaesthetics: Procedures involving digits, ears, nose, penis or scrotum Adverse Effects CNS effects; GI disturbances; epigastric pain; CV disorders; difficulty in micturition with urinary retention; dyspnoea; hyperglycaemia; sweating; (2) Category Route Generic Name Brand Name Mechanism of Action hypersalivation; weakness, tremors; coldness of extremities; hypokalaemia. Gangrene, tissue necrosis and sloughing (extravasation) when used in addition to local anaesthetics. Nursing Interventions (4) Extra (1) Eye drops: Severe smarting, blurred vision, photophobia; naso-lachrymal ducts obstruction. Oedema, hyperaemia and inflammation of the eyes with repeated administration Monitor changes Assess lung Monitor ABGs. In cardiac arrest, of B/P, HR sounds for adhere to ACLS rhonchi, protocols. wheezing, rales WARNING: Use extreme caution when calculating and preparing doses; epinephrine is a very potent drug; small errors in dosage can cause serious adverse effects. Double-check pediatric dosage. NOREPINEPHRINE Medication with picture Sympathomimetic Adrenegic Agonists/Vasopressors IV norepinephrine bitartrate Levophed Stimulates beta1-adrenergic receptors, alpha-adrenergic receptors, increasing contractility, heart rate and producing vasoconstriction. Therapeutic Effect: Increases systemic B/P, coronary blood flow. Indications (2) Acute Hypotension Unresponsive to Fluid Volume Replacement. Contraindications Hypersensitivity to norepinephrine. Hypotension related to hypovolemia (except in emergency to maintain (2) coronary/cerebral perfusion until volume replaced), mesenteric/ peripheral vascular thrombosis (unless it is lifesaving procedure). Category Route Generic Name Brand Name Mechanism of Action Adverse Effects (2) Extravasation may produce tissue necrosis, sloughing. Overdose manifested as severe hypertension with violent headache (may be first clinical sign of overdose), arrhythmias, photophobia, retrosternal or pharyngeal pain, pallor, diaphoresis, vomiting. Hypotension may recur if plasma volume is not maintained. Nursing Interventions (4) Assess ECG, B/P . Be alert to complaint of headache. IV flow rate. Assess for extravasation characterized by blanching of skin over vein, coolness color, temperature of IV site extremity (pallor, cyanosis, mottling). nailbed capillary refill. Monitor I&O; measure output hourly, report urine output less than 30 mL/hr. Once B/P parameter has been reached, IV infusion should not be restarted unless systolic B/P falls below 90 mm Hg. Extra (1) N-OTE FOR EXTRAVASATION O-OUTPUT AND INPUT MONITOR RESTROSTERNAL ADVERSE EFFECT B. Agents for treating Heart Failure CARDIAC GLYCOSIDE LANOXIN Medication with picture Cardiotonic (inotropic) drugs PO AND IV digoxin LANOXIN Inhibits sodium/potassium ATPase pump in myocardial cells. Promotes calcium influx. Increases contractility. chronic atrial fibrillation, fetal tachycardia with or without hydrops; supraventricular tachyarrhythmias Hypersensitivity to digoxin. Ventricular fibrillation. Cautions: Renal impairment, Contraindications sinus nodal disease, acute MI (within 6 mos), second- or third-degree heart block (2) (unless functioning pacemaker), concurrent use of strong inducers or inhibitors of P-glycoprotein (e.g., cyclosporine), hyperthyroidism, hypothyroidism, hypokalemia, hypocalcemia. Category Route Generic Name Brand Name Mechanism of Action Indications (2) Adverse Effects (2) GI disturbances (anorexia, nausea, vomiting), neurologic abnormalities (fatigue, headache, depression, weakness, drowsiness, confusion, nightmares). Facial pain, personality change,ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) may occur. Sinus bradycardia, AV block, ventricular arrhythmias noted Nursing Interventions (4) Assess apical pulse. If pulse is 60 or less/min (70 or less/min for children), withhold drug, contact physician. Blood samples are best taken 6–8 hrs after dose or just before next dose Monitor pulse for bradycardia, ECG for arrhythmias for 1–2 hrs after administration, serum potassium, magnesium, calcium, renal function. . Assess for GI disturbances, neurologic abnormalities (signs of toxicity) q2–4h during loading dose (daily during maintenance). Extra (1) D-EPRESSION ADVERSE EFFECT I-NHIBIT SODIUM/ POTASSIUM ATP PUMP Thrombolytic Agents Alteplase Medication with picture Category Route Generic Name Brand Name Mechanism of Action Indications (2) Thrombolytic Agents Iv and po Alteplase (Activase) Binds to fibrin in a thrombus and converts entrapped plasminogen to plasmin, initiating local fibrinolysis. Therapeutic Effect: Degrades fibrin clots, fibrinogen, other plasma protein Acute MI, Acute Pulmonary Emboli, Acute Ischemic Stroke, Central Venous Catheter Clearance, Usual Neonatal Dosage Contraindications Hypersensitivity to alteplase. Active internal bleeding, AV malformation or aneurysm, bleeding diathesis CVA, intracranial neoplasm, intracranial or (2) intraspinal surgery or trauma, recent (within past 2 mos), severe uncontrolled hypertension, suspected aortic dissection. Adverse Effects (2) Severe internal hemorrhage, intracranial hemorrhage may occur. Lysis of coronary thrombi may produce atrial or ventricular arrhythmias or stroke. Nursing Interventions (4) Assess for contraindications to therapy. Obtain baseline B/P, apical pulse. Record weight. Evaluate 12-lead ECG, cardiac enzymes, electrolytes. Assess Hct, platelet count, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen level before therapy is instituted. Type And screen blood. Perform continuous cardiac monitoring for arrhythmia. Check peripheral pulses, Monitor for chest pain relief and notify physician of continuation or recurrence (note location, type, intensity). Assess for bleeding. Extra (1) Keep in mind that the drugs under thrombolytic agents usually ends with “ase” Reteplase (Retavase) Medication with picture Category Route Generic Name Brand Name Mechanism of Action Indications (2) Thrombolytic Agents Intravenous Reteplase (retavase) Reteplase binds to fibrin rich clots via the fibronectin finger-like domain and the Kringle 2 domain. The protease domain then cleaves the Arg/Val bond in plasminogen to form plasmin. Plasmin in turn degrades the fibrin matrix of the thrombus, thereby exerting its thrombolytic action. For lysis of acute pulmonary emboli, intracoronary emboli, and management of myocardial infarction. acute ST-elevation myocardial infarction (STEMI) to reduce the risk of death and heart failure. Contraindications Active internal bleeding, Recent stroke, Intracranial or intraspinal surgery or serious head trauma within 3 months, Intracranial conditions thaT increase the (2) risk of bleeding (e.g. neoplasms, arteriovenous malformation, or aneurysms), Bleeding diathesis and current severe uncontrolled hypertension Adverse Effects (2) Nursing Interventions (4) Extra (1) Reperfusion arrhythmias, hypotension, Dizziness, fever, severe headache, Anemia, cholesterol embolization, GI/GU bleeding, intracranial hemorrhage, Nausea, vomiting, Cardiac reinfarction, Cardiogenic shock, Muscle pain, Allergic reaction, injection site reaction Watch for signs of bleeding. Be alert for signs of intracranial bleeds, including sudden severe headache, confusion, vomiting, paralysis, numbness, speech problems, and visual disturbances. signs of recurrent cardiac ischemia (chest pain, pain radiating into the arm or jaw, shortness of breath, dizziness, sweating, anxiety) or recurrent peripheral arterial thrombosis (pain, cramping, coldness, cyanosis in the affected limb) Notify physician immediately if these signs occur. Assess blood pressure, muscle of joint pain Assess injection site during and after IV administration, and report signs of bleeding or phlebitis (local pain, swelling, inflammation). Keep in mind that the drugs under thrombolytic agents usually ends with “ase”