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Metoclopramide often causes extrapyramidal reactions rapid effects and continued for 2 to 3 days discount 100mg kamagra soft overnight delivery erectile dysfunction drug therapy. The 5-HT receptor antagonists (eg 100 mg kamagra soft for sale what medication causes erectile dysfunction, ondansetron) are dren who do not respond to other antiemetic drugs. However, the drug should be used cautiously in chil- They may be given in a single daily dose. Metoclopramide, given intravenously in high doses, may be used alone or in combination with various other drugs. Diphenhydramine (Benadryl) may be Use in Older Adults given at the same time or PRN because high doses of metoclopramide often cause extrapyramidal effects Most antiemetic drugs cause drowsiness, especially in older (see Chap. Various combinations of antiemetic and sedative-type be made to prevent nausea and vomiting when possible. A adults are at risk of fluid volume depletion and electrolyte im- commonly used regimen for prophylaxis is a cortico- balances with vomiting. Cholestatic jaundice has been reported than young or middle-aged adults. Dronabinol normally undergoes extensive first-pass hepatic metabolism to active and inactive metabolites. Use in Renal Impairment Resultant plasma levels consist of approximately equal portions of the parent drug and the main active metabo- Several drugs are commonly used for clients with renal im- lite. In addition, the drug is eliminated mainly by bil- pairment who have nausea and vomiting. Metoclopramide dosage should be reduced in clients at recommended doses may lead to accumulation of with severe renal impairment to decrease drowsiness toxic amounts of the drug and its metabolite, even in and extrapyramidal effects. Phenothiazines are metabolized primarily in the liver, In clients with hepatic impairment, more of the par- and dosage reductions are not usually needed for clients ent drug and less of the active metabolite are likely to with renal impairment. Thus, therapeutic and adverse anticholinergic effects and can cause urinary retention effects are less predictable. They also can cause ex- tion can decrease metabolism and excretion in bile so trapyramidal symptoms and sedation in clients with that accumulation is likely and adverse effects may be end-stage renal disease (ESRD). The drug should be used very cautiously, if at all, in clients with moderate to severe hepatic impairment. Use in Hepatic Impairment Most antiemetic drugs are metabolized in the liver and should be used cautiously in clients with impaired hepatic function. With oral ondansetron, do not exceed an 8-mg dose; with IV use, a single, maximal daily dose of 8 mg is Antiemetics are usually given orally or by rectal suppository recommended. Phenothiazines are metabolized in the liver and elimi- clients for possible causes of nausea and vomiting and assist nated in urine. In the presence of liver disease (eg, cir- clients and caregivers with appropriate use of the drugs and rhosis, hepatitis), metabolism may be slowed and drug other interventions to prevent fluid and electrolyte depletion. For prevention of motion sickness, give antiemetics 30 min To allow time for drug dissolution and absorption before travel and q4–6h, if necessary. For prevention of vomiting with cancer chemotherapy and Drugs are more effective in preventing than in stopping nausea and radiation therapy, give antiemetic drugs 30–60 min before vomiting. Inject intramuscular antiemetics deeply into a large muscle To decrease tissue irritation mass (eg, gluteal area). In general, do not mix parenteral antiemetics in a syringe To avoid physical incompatibilities with other drugs. Omit antiemetic agents and report to the physician if the To avoid potentiating adverse effects and central nervous system client appears excessively drowsy or is hypotensive. With dolasetron: (1) Give oral drug 1–2 h before chemotherapy; give IV For oral administration to clients who cannot swallow tablets, drug about 30 min before chemotherapy. When (2) Give IV drug (up to 100-mg dose) by direct injection kept at room temperature, the diluted oral solution should be used over 30 sec or longer or dilute up to 50 mL with 0. Excessive sedation and drowsiness Excessive sedation may occur with usual doses of antiemetics and is more likely to occur with high doses. Anticholinergic effects—dry mouth, urinary retention These effects are common to many antiemetic agents and are more likely to occur with large doses. Hypotension, including orthostatic hypotension Most likely to occur with phenothiazines; may also occur with 5-HT3 antagonists d.
In this chapter generic kamagra soft 100mg visa impotence libido, the drugs are discussed only in ing on the dose being used cheap kamagra soft 100 mg free shipping erectile dysfunction labs. In addition, dopamine acts indi- relation to their use in hypotension and shock. In these con- rectly by releasing norepinephrine from sympathetic nerve ditions, drugs with alpha-adrenergic activity (eg, norepi- endings and the adrenal glands. Peripheral dopamine recep- nephrine, phenylephrine) are used to increase peripheral tors are located in splanchnic and renal vascular beds. Some drugs have both accepted that stimulation of dopamine receptors by low alpha- and beta-adrenergic activity (eg, dopamine, epi- doses of exogenous dopamine produces vasodilation in the nephrine). In many cases, a combination of drugs is used, renal circulation and increases urine output. More recent studies indicate that low-dose dopamine enhances renal function only when cardiac function is improved. At doses greater than 3 mcg/kg/min, dopamine binds to beta and alpha TABLE 54–1 Types of Shock receptors and the selectivity of dopaminergic receptors is lost beyond 10 mcg/kg/min. At doses that stimulate beta receptors Clinical Types of Shock Possible Causes Manifestations (3 to 20 mcg/kg/min), there is an increase in heart rate, myo- cardial contractility, and blood pressure. At the highest doses Hypovolemic Trauma Hypotension (20 to 50 mcg/kg/min), beta activity remains, but increasing Gastrointestinal bleed Tachycardia alpha stimulation (vasoconstriction) may overcome its actions. Ruptured aneurysms Cool, clammy skin Third spacing Dopamine is useful in hypovolemic and cardiogenic shock. Diaphoresis Dehydration Pallor Adequate fluid therapy is necessary for the maximal pressor Oliguria effect of dopamine. Acidosis decreases the effectiveness of Cardiogenic Acute myocardial in- Signs and symptoms dopamine. It acts mainly on Dysrhythmias of decreased Cardiomyopathy cardiac output beta1 receptors in the heart to increase the force of myocardial Distributive contraction with a minimal increase in heart rate. Dobutamine Neurogenic Spinal cord damage Hypotension also may increase blood pressure with large doses. It is less Spinal anesthesia Bradycardia likely to cause tachycardia, dysrhythmias, and increased myo- Severe pain Warm, dry skin cardial oxygen demand than dopamine and isoproterenol. It is Drugs most useful in cases of shock that require increased cardiac Septic Infection (eg, urinary Hypotension tract, upper respira- Cool or warm, dry skin output without the need for blood pressure support. It is tory infections) Hypothermia or hyper- recommended for short-term use only. It may be used with Invasive procedures thermia dopamine to augment the beta1 activity that is sometimes Anaphylactic Contrast dyes Hypotension overridden by alpha effects when dopamine is used alone at Drugs Hives doses greater than 10 mcg/kg/min. Insect bites Bronchospasm Foods Dobutamine has a short plasma half-life and therefore must be administered by continuous IV infusion. A loading 790 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM Drugs at a Glance: Drugs Used for Hypotension and Shock Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Dopamine (Intropin) Increase cardiac output IV 2 to 5 mcg/kg/min initially, gradually Same as adults Treat hypotension increasing to 20–50 mcg/kg/min if Increase urine output necessary. Prepare by adding 200 mg of dopamine to 250 mL of IV fluid for a final concentration of 800 mcg/mL or to 500 mL IV fluid for a final con- centration of 400 mcg/mL. Reconstitute the 250-mg vial with 10 mL of sterile water or 5% dex- trose injection. The resulting solu- tion should be diluted to at least 50 mL with IV solution before admin- istering (5000 mcg/mL). Add 250 mg of drug to 500 mL of diluent for a concentration of 500 mcg/mL. IV direct injection, 100–1000 mcg of 1:10,000 injection, every 5–15 min, injected slowly. Prepare the solution by adding 1 mL epinephrine 1:1000 to 9 mL sodium chloride injection. Milrinone (Primacor) Increase cardiac output in IV injection (loading dose), 50 mcg/kg cardiogenic shock over 10 min. Norepinephrine Treat hypotension IV infusion, 2–4 mcg/min, to a maxi- IV infusion, 0. Phenylephrine Treat hypotension IV infusion, 100–180 mcg/min initially, SC, IM 0. Prepare solution by adding 10 mg of phenylephrine to 250 or 500 mL of IV fluid. CHAPTER 54 DRUGS USED IN HYPOTENSION AND SHOCK 791 dose is not required because the drug has a rapid onset of ac- cardial contraction, and coronary artery blood flow.
