Meds for Life

Disclaimer: This website does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on this website. If you think you may have a medical emergency, immediately call your doctor or dial 911. Readers are encouraged to confirm the information herein with other sources. The author is not responsible for errors or omissions. Please contact admin@chphil.com for errata.

MEDS FOR LIFE

ANTICOAGULATION:

  • Warfarin (Coumadin) 2-10mg PO OD, target INR 2-3
  • Fondaparinux (Arixtra) 2.5mg-10mg SQ OD (weight based)
  • Rivaroxaban (Xarelto) 15mg PO BID 3wk, then 20mg PO OD
  • Apixaban (Eliquis) 10mg PO BID 1wk, then 5mg PO BID
    • 2.5mg PO BID if 2 out of 3: age >80, Cr >133, weight <60kg, (for Afib only)
  • Dabigatran (Pradaxa) 150mg PO BID, requires 5d LMWH/UFH bridge
  • Unfractionated Heparin 10,000u IV then 50 to 70 units/kg (5,000 to 10,000u) q4-6h
    • STEMI: Initial 60 units/kg (max: 5,000u) IV Bolus, then 12 units/kg/hour (maximum: 1,000 units/hour) continuous IV until PCI (target aPTT 1.5-2x control or anti-Xa 0.3-0.6, adjust 100-150u/hr)
    • Prophylaxis: 5,000u subcut q8-12h
  • Enoxaparin (Lovenox) 1mg/kg SQ q12h rounded to 10, or 1.5mg/kg SQ OD
    • Prophylaxis: 40mg subcut q24h
  • No LMWH or DOACs in renal failure, good for cancer or pregnancy
  • Anti-Xa target: 0.6-1.2 U/ml (institution dependent)
  • Dalteparin (Fragmin) 200 units/kg SQ OD, max 18,000u/day OR
    • 46 to 56 kg: 10,000 units once daily
    • 57 to 68 kg: 12,500 units once daily
    • 69 to 82 kg: 15,000 units once daily
    • ≥83 kg: 18,000 units once daily
    • Prophylaxis: 5000u subcut q24h
  • Tinzaparin (Innohep) 175 units/kg SQ OD, max 18,000u/day
  • Protamine Sulphate (Antidote UFH) 1-1.5mg per 100u UFH IV slow + continuous
    • If LMWH, 50mg max (60% reversal)
  • Octaplex (PCC – Antidote VKA) – 4 ml/min IV or 3 minute bolus
    • Pretreatment INR: 2 to <4: Administer 25 units/kg; maximum dose: 2,500 units
    • Pretreatment INR: 4 to 6: Administer 35 units/kg; maximum dose: 3,500 units
    • Pretreatment INR: >6: Administer 50 units/kg; maximum dose: 5,000 units
  • Vitamin K 2.5-5mg PO, or 1-10mg IV slow infusion (IV preferred in urgent cases)
  • Tranexamic acid (TXA) 1g IV over 10 mins, q30min – BID/TID x3d
  • TXA (Cyklokapron) 1-1.5g PO 3-4 times daily

 

ANTIPLATELET:

  • Aspirin (ASA) 81-325mg PO OD
  • Dipyridamole
  • Clopidogrel (P2Y12i) 75-300mg PO OD
  • Ticagrelor (P2Y12i) 180mg PO OD initial, or 90mg PO BID
  • GPIIb/IIIa Inhibitors (abciximab, eptifibatide)

 

ANTICHOLINERGIC:

  • Effects: Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone, bladder and bowels lose their tone, heart goes off alone
  • Confusion (delirium), blurry vision (dilated pupils), flushed skin, dry skin (anhidrosis), dry mucous membranes, tachycardia, constipation, urinary retention, bronchodilator (as in COPD)
  • See nausea medications
  • Benztropine (Cogentin) 1-4mg OD/BID PRN, max 6g/d
  • Atropine 0.5mg IV q3-5m (3mg max) – ACLS Bradycardia
  • Buscopan 10-20mg PO/PR/SC/IV q6-8h, q4h PRN (Anti-Chol)
  • Dimenhydrinate (Gravol) 25-50mg PO q4-6h PRN, max 400mg daily (if IV max 25mg q6h) (Anti-H1)
  • Diphenhydramine (Benadryl) 25-50mg PO q4-8h, 10-50mg IV q6h

 

ANTIEPILEPTIC :

  • Lorazepam (Ativan) 0.1mg/kg OR 2-4mg IV repeat x1 q5-10m + 2mg/min PRN infusion
  • IM lorazepam should be double dose of IV
    • Diazepam 0.1mg/kg IV;  Midazolam 0.05mg/kg IV (initial); Midazolam 10mg IM (>40kg)
    • Phenytoin (Dilantin) 1-1.5g/hr IV OR 20m/gkg at 25-50mg/min
    • Fosphenytoin 20mg/kg phenytoin equivalent at 100-150mg phenytoin equivalent/min
    • Midazolam (if refractory) 0.2mg/kg IV bolus at 2mg/min, infusion at 0.1mg/kg/hr titrate upwards until seizure breaks
    • Propofol 1-2mg/kg loading dose over 5 minutes, infusion up to 10-12mg/kg/hr
    • Pentobarbital 5mg/kg over 10 minutes, repeat until seizure breaks
    • Phenobarbital 15-20mg/kg (infused at 50-100mg/min), repeat q10min – can be given SUBCUT

 

AGITATION:

  • Haloperidol (Haldol) 0.25-0.5-1-2-5-10mg PO/IV/IM/SQ q1-6h PRN
  • Methotrimeprazine (Nozinan) 5-6.25-12.5mg PO/SQ q1-4h PRN
  • Quetiapine 50mg po qHS
  • Risperidone 0.125-0.25-1-2mg PO q1-2h PRN
  • Loxapine 2-12.5-25mg IM/PO
  • Lorazepam (Ativan) 0.5-2mg IV/IM q30m PRN
  • Midazolam 1-2.5-5mg IV/IM/SQ q5m or q1h PRN
  • Trazodone 25-50mg PO qHS PRN
  • Mirtazapine (Remeron) 7.5-15mg PO qHS PRN
  • If prior seizures give: BZD or phenobarbital 60-90-120mg subcut/IV q4-6
  • If Parkinson’s/Lewy body: BZD or quetiapine

 

ANALGESIA:

NSAIDs: MOA – inhibition of COX-1 and COX-2 enzymes

  • Ibuprofen (Advil) 200-400mg PO q4-6h PRN, max 1.2g/d
  • Naproxen (Aleve) 250-500mg PO q8-12h, max 1g/d
  • Diclofenac (Voltaren) 50mg PO TID
  • Celecoxib (Celebrex) 200-400 mg OD/BID
  • Ketorolac (Toradol) 10-30mg IV

 

Opioids:

  • Tramadol 25-50mg PO q4-6h PRN, max 400mg/d
  • Tramacet (Tylenol 325mg/Tramadol 37.5mg) 1-2 tab PO OD PRN
  • Tapentadol 50mg q4-6 hr, max 600mg/d
  • Hydromorphone (Dilaudid) 0.5-2mg PO/IM q4h PRN, max 24mg/d
  • Hydromorphone (Dilaudid) 0.1-1mg SC/IV q2-4h PRN
  • Hydromorphone 0.1-1 mg/hr IV infusion (sedation)
  • Oxycodone (OxyNEO, oxycontin) 5-15mg PO q4h PRN, max 60mg/d
  • Morphine 0.1-0.5mg/kg
  • Morphine 5-20mg PO PRN, max 120mg (watchful dose 90mg PO, no true max)
  • Morphine 2.5-10mg IV/SQ q4h PRN, continuous infusion at 0.8-20 mg/hr
  • Note: reduce dose by 33% when opioid converting due to incomplete cross tolerance
  • Hydromorphone 2mg PO = Oxycodone 5mg PO = Morphine 10mg PO =  Codeine 20mg PO = Tapentadol 25mg PO = Tramadol 67mg PO (?)
  • Morphine 100mg PO/24h = Fentanyl 25mcg/hr (patch or CADD subcut)
  • Morphine 10mg IV = Fentanyl 100mcg IV
  • Morphine 10mg PO q4h = 60mg q24h / 4 -> fentanyl patch 15 mcg/h
  • Watchful dose 90mg in non-cancer
  • Long acting e.g. MS Contin (or dilaudid contin) half the total daily short acting dose @ q12h
  • Hydromorphone 1mg IV = Morphine 5mg IV
  • IV/SQ to PO 1:2
  • Fentanyl 25-50mcg IV q6h PRN can do q15min
  • Breakthrough dosing for opioids: 10% of 24hr dose (rounded) q1-2h
  • 25-30% dose reduction for delirium (and switch from morphine to hydromorph), initial 50% reduction in opioid naive/frail patients
  • Liver failure: Tylenol 2g max, fentanyl, tramadol, hydromorphone less
  • Renal failure: Fentanyl, methadone, HM less
  • Naloxone 2mg IV/IM/SL/SC/ETT split dose 0.4-0.6-1mg stepwise q2-3min
  • Consider micro dosing of 0.04mg steps to achieve balance between pain and sedation
  • Infusion dose is 2/3 of effective bolus dose/hr (in cases of slow-release or long-acting opioids)

 

Non-opioids:

  • Acetaminophen (Tylenol) 325-650-975mg PO PRN q4-6h, max 3-4g/d
  • Nabilone (cannabinoid)
  • Ketamine 4-6mg IV or 0.1-1mg/kg/hr (note that induction doses are 0.5-2mg/kg IV push, 50-75-100mg), start 4-6mg/hr infusion appropriate for agitation and pain
  • Baclofen 5mg PO TID, max 80mg/day (muscle relaxant)
  • Gabapentin (Neurontin) 300-900 mg OD/BID/TID, max 2400mg/d (start 100 TID)
  • Pregabalin (Lyrica) 25-150mg OD/BID
  • Duloxetine (Cymbalta) 30-60mg PO OD – SNRI
  • Dexamethasone 10-20mg PO/subcut/IV loading dose, followed by 1-2-4-6mg PO/subcut/IV BID
  • Dexamethasone 10-20mg PO/subcut/IV daily/split BID for 1+ week with slow taper to effective dose
  • Nortriptyline 10-25-100-150mg PO qHS
  • Topical lidocaine 5% gel or patch (toxic dose 5mg/kg without epi, 7mg/kg with epi)

 

ANTIEMETICS:

  • Vomiting Centre: Ach-M (Muscarinic), Histamine (H1), 5HT3
  • Higher cerebral centres (Pain, anxiety, ICP): GABA → Lorazepam, Dexamethasone
  • Chemoreceptor zone (drugs, toxins, lytes): D2, 5HT3, NK1 (substance P)
  • GI Tract (obstruction, constipation, delayed emptying): D2, 5HT3
  • Vestibular Input (Motion): H1, ACh-M → Gravol
  • Complete malignant bowel obstruction: No pro-kinetics, HaLDOL, Gravol, Zofran, Dex, Octreotride

D2 Antagonists:

  • Metoclopramide (Maxeran) 5-10mg PO/SQ/IV TID/QID, q4-6h PRN, max 120g/d (DA R antagonist, prokinetic)
  • Domperidone (Motilium) 5-20mg PO q6-8h, q4h PRN (D2 antagonist, prokinetic)
  • Haloperidol (Haldol) 0.5-2-5mg PO/SC/IV q6-12h, q1h PRN (D2 antagonist)
  • Methotrimeprazine (Nozinan) 5-6.25-12.5-25-50-100 q4-6h PRN (D2 antagonist)
  • Olanzapine (Zyprexa) 2.5-5-10mg PO/IM/?SL QD/BID (D2 antagonist)
  • Prochlorperazine 2.5-10mg IV, max 40mg/day (D2-R antagonist + AntiChol + AntiH)
  • Loxapine (non QT)

Anti-histamine:

  • Dimenhydrinate (Gravol) 25-50mg PO q4-6h PRN, max 400mg daily (if IV max 25mg q6h) (Anti-H1)
  • Gravol is the only clear non-QT prolonging antiemetic
    • Diphenhydramine (Benadryl) 25-50mg PO q6-8h, max 400mg (1st gen Anti-H1)
    • Diphenhydramine (Benadryl) 10-50mg IV/IM q6h, max 400mg
    • Betahistine (Serc) 8-16 mg PO TID  or 24 mg BID, max 48 mg (Anti-H1,H3)
    • Meclizine (Antivert) 25-50mg PO q4-6h PRN (Anti-H1)

Anti-cholinergic:

  • Buscopan (Hyoscine butylbromide) 10-20mg PO/PR/SC/IV q6-8h, q4h PRN (Anti-Chol, for MBO, also slows gastric motility)
  • Scopolamine (Hyoscine hydrobromide) 0.2-0.4mg subcut q2-4h PRN  (Anti-Chol)
  • Scopolamine transdermal patch (motion sickness)

Anti-5HT3:

  • Ondansetron (Zofran) 4-8mg IV/NG/PO q6-8-12h or BID/TID PRN (5HT antagonist)

Other:

  • Dexamethasone 10mg IVx1 followed by 4-8mg PO OD/BID (Corticosteroid) – for MBO
  • Octreotide 200mg TID subQ (for MBO, decreases secretions/increases absorption)
  • Lorazepam (Ativan) 0.5-1-2mg PO/IV/SL q4-6h PRN, up to 10mg/d

 

ANTIBIOTICS:

Penicillins:

  • Penicillin G 2-4M units IV q4-6h, CrCl 10-50: 75% dose
  • Penicillin V 250-500mg PO TID/QID
  • Cloxacillin 2g IV q4-6h

Amino-Penicillins:

  • Ampicillin 1-2g IV q4-6hr, CrCl 10-50: q6-q12
  • Amoxicillin 250-1000mg PO TID, CrCl 10-30: 250-500mg PO q12h
  • Amox-Clav 875/125mg PO BID, CrCl 10-30 250-500mg PO q12h

Anti-pseudomonal PCN:

  • Piperacillin-Tazobactam 3.375-4.5g IV q6h, CrCl<15: 2.25g IV q8h

Carbapenem:

  • Imipenem 500-1000mg IV q6h, adjust to CrCl
  • Meropenem 1g IV q8h (2g if CNS infection), CrCl 25-50: 1g q12h, CrCl 10-25: 0.5 q12h, CrCl<10: 500g 24h
  • Ertapenem 1g IV q24h, CrCl <30: 500g q24h
  • Imipenem 500-100mg IV q6h, adjust to CrCl

1st Cephalosporin:

  • Cefazolin 1-2g IV q8h, CrCl 11-34: 50% dose q12h
  • Cephalexin 250-100mg PO QID, CrCl 10-50: 500mg q8-12h

2nd Cephalosporin:

  • Cefuroxime 125-500mg PO QID, 750-1500mg IV q8h, CrCl 10-30: q24h

3rd Cephalosporin:

  • Ceftriaxone 1-2g IV q24h, 2g IV q12h for CNS
  • Ceftazidime 1-2g IV q8-12h, CrCl 30-50: 1g q12h, CrCl15-30: 1g q12h

4th/5th Cephalosporins: Do these even exist?

Aminoglycosides:

  • Tobramycin 5-7mg/kg IV q24h (Tobra bomb x1 IV in severe cases)
  • Gentamicin 5-7mg/kg IV q24h
  • Amikacin 7.5mg/kg q12h

Fluoroquinolones:

  • Ciprofloxacin 500-750mg PO BID or 400mg IV BID, CrCl 30-50: 250-500 q12h, CrCl 5-30: 250-500 q18h
  • Moxifloxacin 400mg PO/IV daily
  • Levofloxacin 500-750mg PO/IV daily, CrCl 10-19: 250mg q48h
  • Norfloxacin 400mg PO BID, CrCl <30: 400mg daily

Macrolides:

  • Azithromycin 500mg x1 day one, then 250mg PO/IV daily thereafter day 2
  • Clarithromycin 250-500mg PO q6-12h, CrCl <30: dec by 50%
  • Erythromycin 250-500mg PO q6-12h, CrCl<10: dec by 50%

Tetracyclines:

  • Doxycycline 100mg PO q12h
  • Tetracycline 500mg PO QID, CrCl 50-80: q8-12h, CrCl 10-50: q12-24h
  • Tigecycline 100mg IV, then 50mg q12h

Sulfa:

  • Trimethoprim-Sulfamethoxazole (Septra) 1-2 SS/DS tabs PO BID, 5mg of TMP/kg IV q6h (CNS infection), (8-20mg/kg/day IV q6-12h)
  • DS tab = 160mg TMP and 800mg SMX, undiluted IV contains TMP 16mg/ml + SMX 80mg/ml in D5W
  • CrCl 15-30: dec by 50%, CrCl<15: full dose q48h

Clindamycin:

  • Clindamycin 150-450mg PO QID or 300-600mg IV q6-12h

Glycopeptides:

  • Vancomycin 15-20mg/kg IV q12h, can start 1-1.5g IV q12h empirically
  • Trough levels pre-4th dose, or pre-3rd whichever timing fits better and then every 3rd or 4th pre-dose after that
  • Target levels 10-15 for not so serious infections, 15-20 for serious infections

Oxazolidinones: (MAOI, risk of serotonin syndrome)

  • Linezolid 600mg PO/IV q12h

Lipopeptides:

  • Daptomycin 4-6mg/kg q12h, up to 8-12mg/kr in MRSA, CrCl<30: dosing q48h

Misc:

  • Flagyl 500mg PO/IV BID (preferred)/TID, if c. diff then 500mg q8h

 

Empiric Abx:

  • Gram +ve: 1st gen cephalosporins (cephalexin, cefazolin)
  • Gram -ve: 3rd gen cephalosporins (CTX)
  • Anaerobes: Metronidazole
  • Pseudomonas: Ceftaz
  • All of the above: pip-tazo
  • AmpC inducible: Carbapenems (Mero)
  • ESBL: Carbapenems (Mero)
  • MRSA: Vanco
  • VRE: Daptomycin (not for lungs)

Pseudomonal Coverage: Pip-tazo, FQs (except Moxi and Nor), Carbapenems (except Erta), Ceftaz, Cefipime (4th gen), Aminoglycosides

MRSA coverage: Clinda, Doxy, Septra, Vanco, Dapto, Linezolid

 

ANTIFUNGAL/ANTIVIRAL:

  • Fluconazole (Diflucan) 12mg/kg IV/PO loading dose, then 6mg/kg daily (800mg then 400mg) PO daily 7-14d
  • CrCl<50: dec by 50%
    • Caspofungin 70mg IVx1, then 50mg IV daily
    • Anidulafungin 20MG iv X1, THEN 100MG iv DAILY
    • Nystatin 400,000-600,000 units QID; swish in the mouth and retain for as long as possible (several minutes) before swallowing
    • Acyclovir 10mg/kg IV q8h, CrCL 25-50: q12h, CrCl 10-24 q24h, CrCl <10: 50% dose q24h
    • For shingles: 800mg PO five times daily x7d
      • Valacyclovir 1000mg PO TID x7d for shingles
      • Famciclovir 500mg TID x7d for shingles

 

CONSTIPATION:

  • Prune juice PO TID with meals
  • Psyllium (Metamucil/Fibre) 2.5-30g PO OD/BID (bulking agent)
  • Senna 8.6-17.2mg PO QD/BID PRN (stimulant, opiate PPx)
  • Lactulose 10-20mg/15-30ml PO q6h/qhs/OD (osmotic)
  • PEG3350 (Restoralax) 17g PO OD/BID (osmotic )
  • Bisacodyl (Dulcolax): 5-15mg PO daily (stimulant)
  • Suppositories: glycerine, dulcolax (bisacodyl), soap suds, Sodium phosphate fleet (oral or PR – not for renal failure due to high PO4), tap water
  • Golytely 4L PO, last option
  • Methylnatrexone
  • Colace (Docusate) 100mg PO BID (stool softener, opiate PPx) – poor efficacy, do not use

 

DIABETES :

  • Sensitizers: (Take before meals, before breakfast if OD and before supper if OD)
  • Metformin: 250mg OD/BID, max 2500mg + B12 supplement 500-1,000 mcg PO OD (if low)
  • Glitazones (TZD): Rosiglitazone (4mg PO OD/BID max 8mg), Pioglitazone (15mg PO OD max 45mg) – Don’t use TZDs
  • Secretagogues:
  • Sulfonyureas: Glyburide (2.5mg PO OD/BID max 20mg), Gliclazide (80mg PO BID max 320mg), Gliclazide MR (30mg PO OD max 120mg)
  • Meglitinides: Repaglinide 0.5 mg PO AC (every meal) max 4mg/dose or 16 mg/day (good for renal insufficiency)
  • Other:
  • Alpha glucoside inhibitors: Acarbose 25mg PO AC max 100mg (depends on weight!)
  • DDP4-inhibitors (Gliptins): Sitagliptin (100mg PO OD), Linagliptin (5mg PO OD)
  • Incretin (GLP-1) analogues: Liraglutide (0.6mg OD SubQ max 1.8mg), Exenatide
  • SGLT2-inhibitors: Canagliflozin (100mg OD 300mg max), Dapagliflozin (5mg PO OD 10mg max), Empagliflozin (10mg PO OD max 25mg)

 

INSULINS:

  • Long/Basal: NPH, N, Glargine (Lantus), Detemir (Levemir)
  • Medicine: 0.1 – 0.2u/kg/day sc
  • Community: Initiate 5u or 10u qhs sc, Titrate 10% by 1-2u q3-4d until AM FBS = 4 – 7 mmol/L
  • Can split long acting between morning and night if lunch and dinner high sugars
  • If NPO with maint fluids: dec 30-50% basal, d/c bolus
  • If continuous tube feeds: dec 30% basal can do split q12, may consider q6 bolus if required
  • If 12h continuous tube feeds: dec 50% TDD, choose NPH q12 ¼ @2000 ¾ @0800 for daytime feedings, reverse if night time feeding
  • Short/Prandial: Regular (R),Novolin Toronto
  • Rapid: Lispro (Humalog), Aspart (NovoRapid), Glulisine (Apidra)
  • Medicine: Total dose: 0.5u/kg (40% of total dose – basal insulin qHS) 20% of total dose TID with meals (60%) – prandial insulin 15-30 min before meals Eg. 80kg pt – 0.5u/kg = 16u basal (40%); 8u TID (20% x 3 = 60%)
  • Community: Start 5u sc with meals, Titrate AM to HS to target, Monitor 2h PPG, Start injection TID or only single meal as required, If poor control: inj TID sc; If mediocre control: inj qAM sc; Still aim for ~2/3rds split (40% basal / 60% prandial)
  • Premixed: HumuLin, NovoLin
  • Medicine: Estimate total starting daily dose (0.3-0.6 units/kg); Divide daily dose: 2/3 before breakfast; 1/3 before supper
  • Community:  From scratch:  Start 5-10u QD-BID and titrate; From other insulins: Calculate approximate amount of basal and prandial units and divide 2/3rd – 1/3rd AM and PM

 

 

 

 

Correction Scale

Low

Moderate

High

Correction if < 60 U/day

Consider if on 60-100 U/day

Consider if >100 U/day

10.1- 14.0 mmol/l

2 U

3 U

6 U

14.1-18 mmol/l

3 U

4 U

8 U

18.1-22 mmol/l

4 U

6 U

10 U

>22.1 mmol/l

5 U call MD

8 U and call MD

14 U and call MD

 

 

Type of Fluid

ECF = ⅓ TBW

ICF = ⅔ TWB

IVF = ¼ ECF

IF = ¾ ECF

ICF

1000cc D5W 83cc 250cc 667cc
1000cc ⅔ ⅓ 139cc 417cc 444cc
1000cc NS or RL 250cc 750cc 0
500cc 5% Alb 500cc 0 0
100cc 25% Alb 500cc -400cc 0
500cc Pentaspan 750cc -250cc 0
1 Unit RCC 400cc 0 0

TBW = Total body water; ECF = Extracellular fluid, ICF = Intracellular fluid, IVF = intravascular fluid, IF = interstitial fluid, RCC = red cell concentrates

 

FLUIDS:

2/3 + 1/3 + KCl 40mEq (20mEq if elderly or 75cc/hr) at 100cc/hr no cardiac disease and 75cc/hr if cardiac disease/ elderly

0.5-1.0g/kg (1-2 mL/kg) IV of D50W for adults for antidote

  • Deficit: kg x tbw% x % loss (adults), for peds= kg x % loss x 1000
  • Estimate deficit: 3% = History + HR + O/E, 6% = O/E + vitals△, 9% = CNS△ + oliguria
  • H2O losses 4/2/1 rule: first 10kg = 40cc, 2nd 10kg = 20cc, remaining 1 kg = 1 cc
  • Or 40 + kg = cc/hr maintenance required (multiply by 24 for daily loss)
  • In general 4/2/1 rule overestimates, will have fluid overload, 75-100 cc/hr is a good starting point
  • Replenish rate: initial bolus (20cc/kg, subtract bolus from total), half of deficit in first 8 hours, next half over 16 hours
  • Maintenance lytes: Na = 3 mEq/kg/d; K = 1 mEq/kg/day
  • Maintenance glucose: Adults 100-200 g/day; children 100-200 mg/kg/hr
  • Max KCl replacement 80 mg/d recommended, based on K
  • Target 0.5 cc/kg/hr output
  • In peds, use D5NS for maintenance
  • Albumin 100cc 25% for 4-5L drained (paracentesis) (5-10g of of albumin per L of fluid removed), usually 8g

 

  • 3 amps bicarb in d5w bag @ 100-250cc/hr

 

Solution

Osmol

pH

Na

Cl

K

Ca

Glu

Other

ECF

280-310

7.4

142

103

4

NS

308

5.5

154

154

RL

273

6.5

130

109

4

3

28 Lac

D5W

253

4.5

50

½ NS

154

6.0

77

77

3% NS

1026

5.0

513

513

D5W ½ NS

432

4.0

77

77

50

D5W RL

525

5.0

130

109

4

3

50

28 Lac

D5W NS

560

4.0

154

154

50

⅔ D5W ⅓ NS

269

4.0

51

51

33

Albumin 5%

330

7.4

145

<2

50 Alb

Albumin 25%

330

7.4

145

<2

250 Alb

Pentaspan

326

5.0

154

154

Pentastarch

Osmolarity = mOsm/L, Lytes = mEq/L, Glucose or albumin = g/L

Green = isotonic, blue = hypotonic, red = hypertonic

 

ELECTROLYTES:

  • Calcium carbonate  500-750-1000-1250 mg po daily, bid or tid
  • Calcitriol 0.25mcg po daily (form of vitamin D that is used to treat low levels of calcium – renal/ parathyroid)
  • Albumin 25% in 100cc IV (corrected Ca – add 0.2 to Ca for every 10 less than 40 in albumin)

 

HyperKalemia:

  • Calcium gluconate 10ml of 10% solution (1g) IV over 2min (quick save for heart)
  • If non-urgent, infuse over 1hr
    • Calcium Chloride (provides more Calcium compared to Ca-Gluconate) 500-1000mg IV over 2-5min
    • Dextrose 1 amp (50ml of D50W) + 10U regular insulin, repeat POCT glu in 2-4h
    • NaHCO3 50mmol (1 amp) over 5-10 minutes if acidotic
    • Salbutamol 10-20mg neb over 10 min q4h PRN
    • Sodium polystyrene sulfonate (Kayexalate) 15-30g in sorbitol or 100ml H2O PO
    • Furosemide 20-40mg PO/IV q6-8h
    • Fludrocortisone 0.1mg OD/BID PO

 

HypoKalemia: 100-120mEq replacement = ~1 mmol/L of K

  • Mild-mod (K 3.0-3.5):
  • K+ elixir 40mg PO x1-2  (1.3mmol K/mL, target 20-40 mmol/day, 120mEq to inc 1 K)
  • K-lyte (K Bicarb) 1 tab = 25 mmol K
  • KDur 40mg PO BID (large tablet!)
  • KCl (sustained release or Slow-K) 600mg tab PO OD/BID (8 mmol K/tab, target 20-40 mmol/day)
  • If requiring IV fluids, some bags are pre-mixed with KCl, e.g. 2/3 1/3 + 40mmol KCl, NS + 40 KCl
    • Severe (K <3.0): still prefer PO but if require quickly then IV, or NG if PO difficult
    • 4 x (10 mmol kcl mini bag) IV over 4 hours (1h per 10mEq, causes phlebitis)
      • Must check Mg if K is low: <1 and must check if hypoPhos
      • Mg oxide 2 tabs PO (or 420mg PO daily or BID) – may cause diarrhea
      • Mg sulfate 2g IV over 2 hrs (up to 4-5g at a time)

 

Magnesium:

  • 1g MgSO4 IV = 8mEq mg; Mg Oxide 400mg = 20mgEq mg; MgRougier = 0.4 mEq/mL
  • Mg stores intracellular = drop in levels after replacement
  • Consider PO Mg for ongoing Mg losses (but note Oral Mg may cause diarrhea, worsening hypo Mg)
  • IV replacement:
  • Mild-mod (Mg 0.4-0.66) = MgSO4 2g IV x1-2
  • Severe (Mg < 0.4) = MgSO4 5g IV x1
    • PO replacement: (mild or chronic)
    • Mg Oxide = 400mg 1-2 tabs PO daily
    • MgRougier (liquid) = 1-2 tablespoons (15-30mL) 1-3x daily with meals
      • In emergency/ACLS cases, 4g MgSO4 IV empirically

 

Phosphate:

  • Phosphate Novartis 500mg tabs PO = 16mmol PO4 Pper tab
  • Potassium Phosphate IV = KPhos 22/15 mEq (i.e. 15mmol PO4)
  • Sodium Phosphate IV = NaPhos 20/15 mEq (i.e. 15mmol PO4)
  • PO replacement:
  • Mild (PO4 > 0.4-0.5) = 1 mmol/kg elemental/d, 2-4 doses daily (e.g. Phos Novartis 2 tabs x1 or x2)
  • Mod-Sev (PO4 < 0.4-0.5) = 1.3mmol/kg elemental/d, 2-4 doses daily (e.g. Phos Novartis 2 tabs x3-4 doses BID-QID
  • *Reduce dose by 50% if CKD
  • IV replacement:
  • Mild (PO4 > 0.4) = 0.1-0.25 mmol/kg elemental over 6hrs; e.g. NaPhos 20/15 or KPhos 22/15 IV x1
  • Mod-sev (PO4 < 0.4) = 0.25-0.50 mmol/kg elemental over 8-12 hours; e.g. NaPHOS 20/15 or KPhos 22/15 IV x2

 

Iron: (from most to least constipating? – likely varying degrees), alternate day dosing once daily

  • Ferrous Gluconate PO
  • Ferrous Sulfate PO
  • Ferromax 50-300mg PO OD
  • Optifer (Heme-iron) PO
  • Proferrin PO
  • Venofer IV

 

SUPPLEMENTATION:

  • Trickle feeds: ENT-resource 2.0 vanilla, 20cc/hr, flush water q6h
  • Vit B12 1000mcg-1200mcg-2000mcg po daily, 1000mcg IM qmonthly
  • Vit D 1000U po daily
  • Vit E 400U po with supper
  • Vit C 500mg po daily-bid
  • Glucosamine/ Chondroiton 500mg tab – 1 tab po daily
  • Sodium bicarbonate 1000mg po daily-bid
  • VitB and VitC with folic acid (Replavite) 1 tab po qAM

EtOH cocktail:

  • Multivitamins 1 tab PO daily
  • Thiamine 100-250mg IV/IM daily x3-5d, then 100mg PO TID x1-2wk, then 100mg PO daily thereafter
  • Or if not very serious, just do PO
    • Folate 400mcg PO daily (if included in multivit, can omit)
    • Vit B6 2mg PO daily (if included in multivit, can omit

 

PUFFERS:

  • HFA = hydrofluoroalkane inhalers (previously known as metered dose inhaler MDI), can be used with spacer
  • DPI = similar to HFA but uses dry power instead of liquid mist, cannot be used with a spacer
  • SMI =  soft mist inhalers, a slow moving mist that you inhale

 

SABA:

  • Salbutamol (Albuterol/Ventolin) MDI 100mcg 1-2 puffs PRN or 2.5-5mg NEB PRN (up to 40mg/d in severe exacerb)
  • Fenoterol MDI 100mcg 1-2 puffs PRN
  • Terbutaline DPI 500mcg INH PRN

LABA:

  • Formoterol (Foradil) MDI 6-24mcg INH BID, DPI 4.5-9-12mcg, 1-2 doses BID (max 54mcg/d)
  • Salmeterol (Serevent) MDI 25-50mcg INH BID, DPI 50mcg, 1-2 doses BID (max 20mcg/d)

SAMA:

  • Ipratropium (Atrovent) MDI 20mcg 2 puffs QID or 500mcg NEB QID

LAMA:

  • Tiotropium (Spiriva) MDI 18mcg INH daily or SMI 2.5mcg 1-2 doses daily

ICS: (low-medium-high dosage and note different forms available)

  • Beclomethasone (Qvar) MDI 50-100-200+ mcg BID
  • Budesonide (Pulmicort/TEVA) MDI/DPI 100-200-400+ mcg BID, NEB solution 0.125, 0.25, 0.5mg/ml
  • Ciclesonide (Alvesco) MDI 80-160-320+ mcg once daily
  • Fluticasone Propionate (Flovent) MDI/DPI 50-100-125-250+ mcg BID
  • Mometasone (Asmanex) MDI 110-220-440+ mcg one daily

Combination ICS + LABA:

  • Formoterol + Budesonide (Symbicort) DPI 4.5-9mcg/80-160-320mcg 1-2 doses BID
  • Salmeterol + Fluticasone Propionate (Advair) MDI 25mcg/50-125-250mcg or DPI 50mcg/100-250-500mcg 1-2 doses BID
  • Formoterol + Beclomethasone MDI 6mcg/100mcg 1-2 doses BID
  • Vilanterol + Fluticasone Furoate (Breo Ellipta) DPI 25mcg/100-200mcg 1 dose daily
  • Formoterol + Mometasone (Zenhale) MDI 5mcg/50-100-200mcg 1-2 doses BID

 

STEROIDS:

  • S/E: Weight gain, skin thinning, acne, hirsutism, striae, cataract, glaucoma, HTN, PUD, pancreatitis, hepatitis, hypokalemia, amenorrhea, infertility, osteoporosis, AVN, psychiatric, DM, infections/immunosuppresion
  • Prednisone 50mg PO OD x5 days
  • 1.5mg dexamethasone = 8 methylprednisolone = 10mg prednisone = 10mg prednisolone = 40mg hydrocortisone = 50mg cortisone
  • Prednisone 5-60mg PO daily with tapering 5mg/day
  • Day 1: 30mg → 10/5/5/10
  • Day 2: 25mg → 5/5/5/10
  • Day 3: 20mg → 5/5/5/5
  • Day 4: 15mg → 5/5/5/0
  • Day 5: 10mg → 5ac/0/0/5hs
  • Day 6: 5mg → 5ac/0/0/0
  • Prednisone 1mg/kg/day PO (max 80mg/day)
  • Prednisolone 1.5-2mg/kg (max 120mg) every other day
  • COPDe 40-60mg PO 5-14d
  • Taper required if: 20mg+ pred >3 wks, bedtime >5mg pred for more than a few weeks, cushingoid
  • No taper: any dose <3wks, alternate 10mg pred
  • In between, unclear if taper required

 

SKIN:

  • Mupirocin 2% (Bactroban) Ointment TID 3-5-10d
  • Protopic (tacrolimus) (immune modulator, non-steroidal)
  • Erythromycin ointment BID (up to 6-8 weeks)
  • Selenium sulphide shampoo (anti-fungal)
  • Terbinafine (lamasil) cream/gel (anti-fungal)
  • Ketoconazole (Nizoral) 1-2% shampoo/cream/ointment (anti-fungal)
  • Clotrimazole 1-2% cream/ointment (anti-fungal, candidiasis)
  • Itraconazole PO 200mg BID for 1st week of month for 2-3mo (anti-fungal)
  • Nystatin cream/ointment (candida) BID – oral formula for oral candidiasis
  • Hydrocortisone 1% and Clotrimazole 1% cream – 1app daily
  • Zinc oxide 20% paste apply to affected area BID (diaper rash)
  • Topical anti-viral (Acyclovir, Penciclovir) or oral anti-viral (Famiciclovir, Valaciclovir)
  • Permetrin 5% Cream/Lotion (anti-parasitic, scabies)
  • Glaxal base or aquifor moisturizer
  • (x1 steroid potency) Hydrocortisone 1%
  • (x3) Hydrocortisone 2%<, 17-valerate 0.2%, desonide, mometasone furorate
  • (x6) Betamethasone 0.1%, 17-valerate 0.1%, amcinonide
  • (x9) Bethamethasone, diproprionate 0.05%, flucinonide 0.05%
  • (x12) Clobetasol proprionate, betamehtasone, dipropionate ointment, halobetasol propionate

 

 

CARDIAC/BLOOD PRESSURE:

Statins:

  • Atorvastatin (Lipitor) 20-40-80mg po daily
  • Rosuvastatin (Crestor) 20mg po qHS

Thiazides: (NaCl blocker)

  • HCTZ 12.5-25mg PO qAM
  • Chlorthalidone 12.5-25-50-100mg PO OD, max 100mg/d
  • Indapamide 1.25-5mg PO OD
  • Metalozone 2.5-10mg PO 30-60min before furosemide (if diuretic resistant)

Non-DHP CCBs: Heart-specific

  • Verapamil 80-160mg PO TID (if SR, total daily dose will remain same but OD)
  • Verapamil 0.075-0.15mg/kg (usually 2.5-5mg push) IV over 2 min
  • Diltiazem 15-20mg (0.25 mg/kg) slow push IV over 2 min, repeat 0.35 mg/kg in 15-30m
  • Diltiazem 120-480mg PO OD

DHP CCBs: Vessel-specific

  • Amlodipine 2.5-5-7.5-10mg PO OD, max 10mg/d
  • Nifedipine 10-20mg PO TID, max 180mg/d
  • Nifedipine SR: 30-60-90mg PO OD, max 120mg/d

Vasodilators:

  • Hydralazine 10mg PO q6h PRN, max 300mg/d (arterial)
  • Hydralazine 10-20mg IV q4-6h PRN, max 80mg/d
  • Nitroglycerin spray 0.4mg sublingual PRN or q5min x3 (up to 3 doses) (not for R infarct, check V4R and if inferior infarct need to confirm not R infarct involved)
  • Nitroglycerine patch 0.2-0.4-0.8 mg/hr transdermal, 12h on/12h off
  • Nitroglycerine infusion at 5mcg/min IV
  •  increased by 5mcg/min q5min to effect, effective dose is 5-100 mcg/min, max 200 mcg/min
  • Start 50mcg/min, may need pressors
    • Labetalol (α1B1B2): 5-20mg IV bolus, then 20-80mg q10min (crisis) OR 2mg/min IV infusion (loading) then 2-8mg/min, max total 300mg
    • Sodium nitroprusside: 0.25-10 mcg/kg/min (crisis) – NOT for ischemic heart disease
    • Start infusion at 0.25 mcg/kg/min, titrate upward q5min to effect, effective dose is 2-5 mcg/kg/min, max 10
    • More of an arterial dilator, whereas nitroglycerin is more of a venodilator
      • BiDil (Hydralazine/Isosorbide Nitrate): 37.5mg/25mg PO TID

BB:

  • Extended Release Metoprolol Succinate (β1) 12.5mg-25-50, max 200mg, OD
  • Metoprolol Tartrate (β1) 50mg PO  BID, max 400mg/day
  • Metoprolol (β1) 1mg-5mg IV over 1 min, q5min x3
  • Bisoprolol (β1) 1.25-2.5-10mg PO OD, max 10mg/d
  • Atenolol (β1) 50-150mg po qHS
  • Carvedilol (α1β1β2): 3.125mg, max 25mg, BID
  • Labetalol (α1β1β2): 100-800mg PO OD/BID; 10-20mg IV push over 2 minutes q1h PRN (max 80mg/dose; total 300mg/d)
  • Esmolol (fast-acting β1) 0.5mg/kg over 1min followed by 50 mcg/kg/min, can repeat bolus after 4min if response inadequate and increase infusion to 100/150/200 mcg/kg/min (can repeat every 4 min and increase infusion up to 200)

ACEi:

  • Lisinopril 5mg, max 40mg, OD
  • Ramipril 2.5-5-7.5-10mg, max 20mg, PO qhs
  • Perindopril (Coversyl) 2-16mg OD, max 16mg/d
  • Captopril 6.25-50mg PO TID or q6h (fast acting)
  • Enalapril 1.25-10mg PO BID
  • Enalaprilat 0.625-1.25-5mg IV over 5 min q6-8h

ARB:

  • Valsartan 40mg, max 320, OD
  • ARNI/ARB (Sacubitril/Valsartan) (ARNI acts on neprilysin, decreases BNP action) entreso
  • Candesartan

Loop diuretic: (NaKCl blocker)

  • Furosemide/Lasix: 20-40mg, Max 120 (sort of), OD/BID PO/IV (PO:IV = 2:1)
  • Normal renal function -> 40-80mg IV bolus, can give BID if good response, max 80mg
  • Renal insufficiency -> 100-200mg IV bolus, can give BID, max 200mg

K-Sparing diuretic:

  • Spironolactone: 25-37.5mg OD/BID

 

Inotropes:

  • Dopamine
  • Moderate doses 3-10mcg/kg/min: β effects predominate
  • Higher doses 5-15mcg/kg/min: α effects predominate <– preferred dosing range
    • Dobutamine: 2.5-5mcg/kg/min increase 3-5mcg/kg/min, usual range 5-20 mcg/kg/min
    • Milrinone: 50mcg/kg over 10min, then infuse at 0.375-0.75mcg/kg/min, max daily 1.13mg/kg

 

Vasopressors:

  • Norepi (levophed) (α+β1): 0.02-3.5mcg/kg/min titrate upwards to target MAP 65, if MAP not achieved at 3.5 then a second pressor is required (usually vasopressin, or dopamine –  this is site dependent)
  • TOH uses 2-30 mcg/min (non-weight based dosing), don’t bolus
    • Dopamine:
    • Moderate doses 3-10mcg/kg/min: β effects predominate
    • Higher doses 5-15mcg/kg/min: α effects predominate <– preferred dosing range
      • Vasopressin (ADH, AVP): 0.01-0.04 units/min (usually 0.03) or 2 units/h
      • Epi (α+β1,2) 1mg IV bolus or 0.05-0.5mcg/kg/min, from crash cart can push 0.5cc each time
      • Phenylephrine 50-100mcg IV bolus; 0.1-1.0 mcg/kg/min IV infusion (caution in pHTN)
      • Ephedrine

 

Digoxin: NaK ATPase inhibitor

  • Digoxin 0.5mg IV followed by 0.25mg IV q6h x2 for full loading dose, then 0.125-0.25mg PO daily (frail elderly with low BMI should consider 0.0625mg PO daily), therapeutic range 0.6-1.2ng/ml (toxic >2.4)

 

Alpha blocker:

  • Terazosin 2-20mg PO daily (a1 blocker)
  • Phentolamine 1-5mg IV q5-15min push

 

Alpha 2 agonist: Clonidine for anti-hypertensive, Dexmed for sedation

  • Clonidine 0.1mg PO BID, recommended <0.6mg/day, risk of rebound HTN when stopped
  • Dexmedetomidine (Precedex) 1mcg/kg over 10 minutes loading, followed by 0.2-1.5mcg/kg/hr titrated to effect, generally recommended duration <72hrs

 

ACLS:

  • Amiodarone 150mg IV bolus over 10 min, q10-15 min, max 2.2g/d (300mg – arrest), then infusion @ 1 mg/min for 6h, then 0.5 mg/min for 18 hours
  • Amiodarone IV infusion 900-1200mg/d (10-20 mg/kg/day)
  • Procainamide 20-50mg/min, max 17mg/kg, then 1-4mg/min maintenance infusion until suppressed arrhythmia
  • Atropine 0.5-1.0mg IV fast push q3-5m, max of 0.04 mg/kg (max ~3mg/d)
  • Adenosine 6mg IV rapid push over 3 seconds, may repeat 12 mg IV q2-3m x2
  • nDHP CCB (dilt and verap) – see above
  • Epi 1 mg IV q3-5 min no max – for ARREST only, anaphylaxis is 0.3mg IM thigh
  • Lidocaine 1-1.5 mg/kg (~50mg), repeat at 0.5-0.75 mg/kg q5-10 min, max 3 mg/kg (~150mg)
  • Magnesium sulphate 1-2g IV push dilauted in 10 ml NS (may drop BP, renal failure)
  • Sodium bicarbonate 1 mEq/kg IV, may repeat half dose in 10m

 

Receptor effects:

  • α1 effects: vasoconstriction
  • β1 effects:
  • Heart: HR+ (SA node), conduction+ (AV), contractility+
  • Posterior pit: ADH secretion
  • Kidney: vasoconstriction, renin release
    • β2 effects:
    • Arterial vasodilation (and bronchodilation)
    • Kidney: Renin release (BP+), vasodilation

 

THROAT and NOSE MEDICATIONS:

  • Throat lozenge 1 loz po tid PRN
  • Nystatin 500,000U swish and swallow qid
  • Saliva substitute 1 spray po PRN
  • Normal saline spray 1 spray nasal q4h PRN
  • Cetirizine (Reactine) 5-10mg PO daily (2ng gen Anti-H1)
  • Loratidine (Claritin) 5mg PO OD/BID(2nd gen Anti-H1)
  • Steroid nasal sprays q12 2-3w: flunisolide (Rhinalar), budesonide (Rhinocort), Triamcinolonoe (nasacort), Beclomethasone (beconase), mometasone furoate monohydrate (nasonex)
  • Nasal lubricants: Saline, NeilMed, Rhinaris, Secaris, Polysporin, Vaseline
  • Decongestants: Xylometazoline (Otrivin), Oxymetazoline (Dristan), Phenylephrine (Neosynephrine)

 

EYE DROPS:
▪   Latanoprost eye drops – 1 drop in each eye qHS
▪   Cosopt eye drops – 1 drop in each eye bid
▪   Tobradex eye drops 2 drops in each eye q4h
▪   Timolol 0.5% eye drops 1 drop in both eyes bid

 

GI MEDICATIONS: *WIP*

  • Pantoprazole 40mg PO daily/ bid or 40mg IV bolus BID (PPI)
  • Pantoprazole 80mg IV then 8mg/hour infusion for 72h
  • Octreotide 50mcg IV bolus followed by 50mcg/hr infusion (Somatostatin)
  • Metoclopramide (Maxeran) 5-10mg SQ ac and qHS (DA R antagonist and pro-kinetic)
  • Metoclopramide (Maxeran) 5-10mg po/IV q6h PRN
  • Erythromycin IV 3mg/kg over 5 minutes (at least 15 minutes prior to EGD)
  • Ranitidine (Zantac) 75-150mg PO BID (H2 receptor antagonist)
  • Antacid 30ml po bid PRN
  • Domperidone 10mg po daily-tid (peristaltic stimulant)
  • Budesonide 9mg po daily (steroid)
  • Cholestyramine 4g po daily (prevents bile acid absorption, anti-diarrheal)
  • Anusol 1 application pr PRN (hemorrhoids)
  • Pink lady (1:1 lidocaine 2% viscous + antacid 30ml)
  • Calcium carbonate 500mg PO QID PRN (Antacid)
  • Sucralfate 1g ac meals/tid PO (for ulcers/acid)
  • Loperamide (Imodium) 4mg PO , max 16mg/day – (gut opioid receptor) NOT for gastro

 

 

ORDER SETS:

ANAPHYLAXIS

  • Epi (1:1000) 0.3-0.5mg IM lateral thigh (which is 0.3-0.5 mL from the 1:1000 syringe)
  • Epi (1:1000) 5-15 mcg/min IV
  • Diphenhydramine (Benadryl) 50mg IM/IV (1st gen anti-H1) OR cetirizine (reactine) 10mg PO x1 (2ng gen anti-H1)
  • Ranitidine 50mg IV (anti-H2)
  • Methylprednisone 125mg IV or 1mg/kg IV q6h x 24h
  • If on β-blockade, glucagon 1-5mg IV over 5 min, then infuse 5-15mcg/min titrated to response
  • May consider a SABA (ventolin)

 

UPPER GI BLEED

  • Pantaloc 80mg IV bolus, then infuse at 8mg/h x 48-72 hours (or 40mg IV BID x48-72hr)
  • Obtain 2 large bore IV
  • CBC, type and screen, transfuse as necessary
  • Octreotide 50 mcg IV bolus then 50 mcg/h after  (splanchnic artery vasoconstriction)
  • NS 1L bolus
  • Ceftriaxone 2g IV x 1 then 1g q24 h x 5 days

 

MIGRAINE ORDERS:

  • NS 1L bolus
  • Metoclopramide (Maxeran) 10 mg IV
  • Ketorolac (Toradol) 10-30mg IV
  • Acetaminophen 975mg PRN q4-6 hrs, max 4g/day
  • Magnesium 1g IV over 15 minutes
  • Dexamethasone 10mg IV (for chronic)
  • Intranasal sphenopalatine ganglion block 3cc of 2% lido without epi, slow administration over 30 seconds

 

PALLIATIVE:

  • Glycopyrrolate 0.2-0.4mg subcut q2-4h PRN for secretions (less sedating)
  • Hyoscine Hydrobromide (Scopolamine) 0.2-0.4mg subcut q2-4h PRN for secretions (more sedating)
  • Eyes: artificial tears, lacri-lube eye ointment
  • Noses: Salinex nasal gel
  • Oral: Regular mouth care, gels, biotene
  • GI: Suppository PRN, Tylenol PR PRN
  • GU: Pads, foley PRN
  • Skin: Pressure area care
  • D/C Vitals, investigations, life-prolonging treatments, ICD, ?oxygen, fluids
  • ROS: Pain, dyspnea, anxiety, delirium, PO intake, bowel/bladder function, goals of care, mood