Anaphylaxis

Epinephrine

IM: 0.3 or 0.5 mg (use 0.5 mg in patients >50 kg) using the 1 mg/mL solution.

IM, in the anterolateral aspect of the middle third of the thigh

May repeat every ~5 to 15 minutes (or sooner if clinically indicated) if patient does not adequately respond.

Children dose: 0.01 mL/kg

Glucagon

In patients taking oral beta-blockers.

1-mg bolus followed by 1-mg/hour infusion

Children dose: 20 to 30 mcg/kg

Antihistamine

May need Inhaled beta-agonists, IV fluids, intubation and vasopressors

Urinary Symptoms

Bladder spasm

Oxybutynin (Ditropan)- immediate release: 5 mg 2 to 3 times daily

Belladonna & Opium- suppository- 16mg -60mg, once or twice daily

Urised

Dysuria

Phenazopyridine (Pyridium)- 200 mg orally 3 times a day

Itching

Diphenhydramine (Benadryl)- 25 to 50 mg orally or IV

ENT Symptoms

Sore throat

Chloraseptic spray: 2 sprays q 2hrs PRN

Pulmonary Symptoms

Acute Asthma

Albuterol (Ventolin, ProAir):

Metered-dose inhaler: Initial: (90 mcg/actuation): 2 inhalations qid, PRN

Fluticasone (Flovent): Metered-dose inhaler: Initial: 88 mcg bid

Gastrointestinal Symptoms

Nausea and vomiting

Ondansetron (Zofran) 4 mg IV / PO q 6 hrs PRN

Promethazine (Phenergan) 12.5 mg IV q 4-6 hrs PRN

Metoclopramide (Reglan) 10 mg IV /PO q 6 hrs PRN

Hiccups

Baclofen initial: 5 to 10 mg, PO, 3 times daily

Metoclopramide, Pantoprazole , and Gabapentin may also be tried.

Reflux

Famotidine (Pepcid) 20 mg, IV / PO, bid

Pantoprazole (Protonix) 40 mg IV / PO daily or bid

Calcium carbonate (Tums)

Chewable Tablets- 1000 mg orally up to 4 times a day

Ileus

Chewing gum: helps to prevent ileus

Alvimopan (Entereg) 12 mg PO, bid- after radical cystectomy

Do not give if patient took opioids >7 days before starting this.

Constipation

Docusate (Colace) 50 to 300 mg PO daily divided in 1 to 4 doses

Bisacodyl (Dulcolax) Suppository:10 mg daily, PO : 5 to 15 mg daily

Senna 2 tablets once a day. Tablets are 8.6 mg

MiraLAX (polyethylene glycol)

17 g (diluted in 8 ounces of water or juice, or soda) orally once a day

Fleet enema (sodium phosphates)

120 mL ,rectally as a single dose.

Diarrhea

If not infectious.

Loperamide (Imodium)

Oral: Initial: 4 mg, followed by 2 mg after each loose stool (maximum: 16 mg/day)

Diphenoxylate/ atropine (Lomotil)

5 mg diphenoxylate/0.05 mg atropine (2 tablets) PO q6hr

Opium tincture

Oral: 6 mg (0.6 mL) of undiluted opium tincture (10 mg/mL) 4 times daily

Insomnia

Melatonin

0.1 - 0.5 mg PO

Trazodone

immediate release: PO, 50 mg to 100 mg at bedtime

Zolpidem (Ambien)

5 mg PO q.h.s PRN

Pain Management-Opioids

Oral is preferred than IV. If IV needed, PCA is preferred.

Should prescribe the lowest effective dose of immediate-release opioids.

Should carefully reassess risks and benefits when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day.

Should avoid dosage ≥90 MME/day.

Three days or less will often be sufficient.

More than seven days will rarely be needed.

Should avoid prescribing opioid and benzodiazepines concurrently.

Oral Narcotics MME Calculator

Oxycodone (Oxycontin)

Oxycodone/acetaminophen (Percocet)

Oral: Immediate release

Dose: Based on oxycodone content:

2.5 to 10 mg every 4 to 6 hours PRN

Elderly >70 years: Decreasing the initial dose by 25% to 50%.

Dosing: Altered kidney function: There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic impairment: There are no dosage adjustments provided in the manufacturer’s labeling.

Hydromorphone (Dilaudid)

Oral: Immediate release

2 to 4 mg every 4 to 6 hours PRN

IV: 0.2 to 1 mg every 2 to 3 hours as needed PRN

Patient-controlled analgesia (PCA)

Loading dose: 0.4 mg

Demand dose: Range: 0.1 to 0.4 mg

Lockout interval: 10 minutes

Dosing: Altered kidney function

CrCl 30 to <60 mL/minute: Administer 50% of usual initial dose.

CrCl <30 mL/minute:

Administer 25% of usual initial dose and extend dosing interval by 25% to 50%.

Dosing: Hepatic impairment

Mild to severe impairment: Initiate with 25% to 50% of the usual starting dose depending on the degree of impairment.

Morphine

IV: 1 to 4 mg every 1 to 4 hours PRN

Dosing: Altered kidney function

CrCl 30 to <60 mL/minute: Consider use of an alternative opioid analgesic. If necessary, administer 50% to 75% of usual initial dose; may also consider extending dose interval.

CrCl 15 to <30 mL/minute: Avoid use. If necessary, administer 25% to 50% of usual initial dose; may also consider extending dose interval.

CrCl <15 mL/minute: Avoid use.

Dosing: Hepatic impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Fentanyl

Used for analgesia and sedation in critically ill patients in the ICU.

Loading dose: IV: 25 to 100 mcg or 1 to 2 mcg/kg

Continuous infusion:

After initial loading dose begin continuous infusion.

Initial rate: 25 to 50 mcg/hour

Titrate every 30 to 60 minutes to clinical effect pain control and/or sedation)

Usual dosing range: 50 to 200 mcg/hour

Dosing: Altered kidney function

CrCl <50 mL/minute:

No dosage adjustment necessary when single or infrequent bolus doses are used.

For more frequent dosing, use small, incremental doses to titrate.

Dosing: Hepatic impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Pain Management- Others

The transversus abdominis plane (TAP) block

Thoracic epidural analgesia

It should be continued for 72 h

Ketorolac (Toradol) - IV

Weight ≥50 kg and <65 years of age

15 to 30 mg q 6 hr, PRN

Weight <50 kg or ≥65 years of age

15 mg q 6 hr, PRN

Acetaminophen (Tylenol)

650 mg PO or PR q 6 hrs PRN

Gabapentin

Immediate release: Initial: PO, 100 to 300 mg 1 to 3 times daily

Pregabalin

Immediate release: Initial: PO, 25 to 150 mg/day in 2 to 3 divided doses

Tramadol

≤3 days is often adequate

>7 days is rarely needed

Immediate release: Initial: 50 mg, PO, every 4 to 6 hours PRN

The dose may be increased as needed and tolerated to 50 to 100 mg every 4 to 6 hours (maximum: 400 mg/day)

Dosing: Altered kidney function

CrCl <30 mL/minute:

Immediate release: Increase dosing interval to every 12 hours; maximum: 200 mg/day.

ER formulation should be avoided.

Dosing: Hepatic Impairment

Severe impairment:

Immediate release: 50 mg every 12 hours

DVT Prophylaxis

Extended prophylaxis for 4 weeks should be carried out in patients at risk.

Options:

One or combination of following measures depending on patient risk:

Heparin

5000 units q8h or q12h SC

BMI ≥30: 5000 units q8h

Contraindications to Prophylactic Heparin

Hypersensitivity to heparin

Severe thrombocytopenia

History of heparin-induced thrombocytopenia

History of heparin-induced thrombocytopenia with thrombosis

Uncontrolled active bleeding

Heparin Dose: Altered Kidney Function

No initial dosage adjustment necessary

Heparin Dose: Hepatic Impairment

No dosage adjustment required

Enoxaparin (Lovenox)

40 mg SC daily

If CrCl <30 mL/min: 30 mg SC daily

BMI ≥40: 40 mg twice daily

Contraindications to Prophylactic Enoxaparin

Hypersensitivity to enoxaparin, heparin, and pork products

History of heparin-induced thrombocytopenia (HIT)

Active major bleeding

Spinal/epidural anesthesia

Epidural catheter

Intra-cranial Pressure (ICP) Monitor

Enoxaparin Dose: Altered Kidney Function

CrCl <30 mL/minute: 30 mg once daily.

Enoxaparin: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling

Epidural

Enoxaparin

Hold prophylaxis for 24 hours prior to epidural placement.

Should not be used while epidural is in place.

Heparin

Hold dose for 6 hours prior to epidural placement.

Hold dose for 4 hours prior to epidural removal.

Resuming prophylaxis

May initiate subcutaneous heparin or enoxaparin 2-4 hours after epidural removal.