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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Rivaroxaban $ Direct inhibitor of factor Xa. Indication and dose
VTE prophylaxis after hip/ knee replacement 0mg/ 24h for 4d for
knees, 5wk for hips (start 6– 0h after surgery);
Initially 5mg/ 2h for 2d then 20mg/24h; For prophylaxis of re-
PE
current PE/ DVT 0mg/ 24h; Prophylaxis of stroke and systemic em-
bolism innon- valvular AF and one risk factor (Such as previous stroke or
Treatment of DVT/
TIA, symptomatic heart failure, DM, HTN, or >75yr) 20mg/ 24h;
Prophylaxis of atherothrombotic events following ACS with elevated cardiac biomarkers (In combination with aspirin alone or aspirin and clopidogrel.)
2.5mg/ 2h for 2mth.
Caution Avoid in patients with signicant bleeding
risk. Wait 6h after last dose before removing epidural catheter and wait 5h
until next dose
SE Haemorrhage, abdominal pain, constipation, diarrhoea,
dizziness, dyspepsia, headache, hypotension, nausea, pain in extremities,
pruritus, rash, renal impairment, vomiting
Info No routine anticoagulant
monitoring required (INR tests are unreliable). Take doses >0mg/ 24h
with food. Reduce dose in renal impairment.
Rosuvastatin $ HMG CoA reductase inhibitor. See statin.
(r) tPA $ Plasminogen activator. See brinolytic.
Salbutamol $ β
200micro grams aerosol/ 200– 400micrograms powder INH PRN
agonist. Dose Chronic airways disease 00–
2
(max 400– 800micro grams/ 24h in divided doses); 2.5– 5mg/ 4h NEB;
Status asthmaticus 2.5– 5mg/ PRN NEB; 250micrograms/ STAT (diluted
to 50micrograms/ mL) slow IV, followed by maintenance infusion of
3– 20micrograms/ min (3– 24mL/ h of the 50micrograms/ mL solution),
titrated to H R
airway obstruction, eg COPD, iK
hyperthyroidism
Indication Asthma; chronic and acute, other reversible
SEFine tremor, nervous tension, headache, palpitation,
+
CautionCardiovascular disease, DM,
muscle cramps.
Salmeterol $ Long- acting β
INH
Indication Chronic asthma, reversible airway obstruction Caution
Cardiovascular disease, DM, hyperthyroidism
agonist. Dose 50– 00micrograms/ 2h
2
SE Fine tremor, nervous
tension, headache, palpitation, muscle cramps.
Sando- K
®
$ Potassium salt. See potassium oral supplement.
SennaSee laxatives.
Seretide
®
$ Long- acting β2 agonist with corticosteroid. Dose 25–
50micrograms salmeterol with 50– 500micrograms uticasone/ 2–
24h INH (depends upon inhaler device, see BNF)
(E p. 287)
TB
SE Fine tremor, nervous tension, headache, palpitation, muscle
Caution Cardiovascular disease, DM, hyperthyroidism,
Indication Asthma
cramps, oral candidiasis, hoarse voice, paradoxical bronchospasm (rare)
InteractionSee salmeterol and uticasone.
Sertraline $ Selective serotonin re- uptake inhibitors. Dose50mg/ 24h
PO increased by 50mg increments at intervals of at least wk until desired eect (max 200mg/ 24h)
order
CI Hepatic or renal impairment, active maniaCaution Pregnancy,
epilepsy, cardiac disease, DM
loss
InteractionMAOI within 2wk, inhibits P450 enzymes.
Indication Depression, OCD, panic dis-
SE GI disturbance, anorexia, weight
213PHARMACOPOEIA
214 CHAPTER 5 Pharmacopoeia
Sevredol
®
$ Opioid. See oral morphine.
SGLT2 inhibitors $ Reduce glucose reabsorption in renal PCT.
DoseSee Table5.9Indications T2DM, growing evidence for use in CCF
with reduced ejection fraction
atic impairment, severe renal impairment
at risk of volume depletion
UTI, hypoglycaemia
Info Risk of euglycaemic diabetic ketoacidosis, must
CI Pregnancy, breastfeeding, severe hep-
Caution Hypotension, patients
SE Balanoposthitis, dizziness, increased risk
be stopped in acute illness and prior to surgery.
Table5.9 SGLT2 inhibitors
Canagliozin Dose 00mg/24h PO, increased to 300mg/24h before breakfast
Dapagliozin Dose 0mg/24h PO
Empagliozin Dose 0mg/24h PO increased to 25mg PO if necessary
Ertugliozin Dose 5mg/24h PO increased to 5mg PO if necessary
Simvastatin $ HMG CoA reductase inhibitor. See statin.
SitagliptinSee DPP-4 inhibitors.
®
Slow- K
$ Potassium salt. See potassium oral supplement.
Sodium valproate $ Antiepileptic. See valproate.
SotalolSee beta- blockers.
Spironolactone $ Potassium- sparing diuretic (aldosterone antag-
onist).
Dose 25– 200mg/ 24h PO (max 400mg/ 24h) Indication Oedema/
ascites in cirrhosis/ malignancy, nephritic syndrome, congestive heart failure
CI Pregnancy, breastfeeding, hyperkalaemia, hyponatraemia, Addison’s
disease
Caution Renal impairment, porphyriaSEGI disturbance, impotence,
gynaecomastia, menstrual irregularities
lithium levels; risk of iK
+
when used with ACEi or AT II receptor antagonists.
Interaction Increases digoxin and
Statins $ HMG CoA reductase inhibitor. DoseSee Table5.20 Indications
Dyslipidaemias, primary and secondary prevention of cardiovascular disease
(irrespective of serum cholesterol)
thyroidism, hepatic impairment, high alcohol intake,
CautionPregnancy, breastfeeding, hypo-
SE Myalgia, myositis (in
severe cases rhabdomyolysis), GI disturbance, pancreatitis, altered LFTs
(rarely hepatitis/ jaundice)
Interaction Avoid concomitant use of macrolide
antibiotics and amiodarone (possible increased risk of myopathy).
Table5.20 Statins
Atorvastatin Dose Initially 0mg/ 24h PO up to max 80mg/ 24h PO
Fluvastatin Dose Initially 20mg/ 24h PO up to max 80mg/ 24h PO
Pravastatin Dose Initially 0mg/ 24h PO up to max 40mg/ 24h PO
Rosuvastatin Dose Initially 5mg/ 24h PO up to max 40mg/ 24h PO
Simvastatin Dose Initially 0mg/ 24h PO up to max 80mg/ 24h PO
Stemetil
®
$ Phenothiazine. See antiemetic.
Streptokinase $ Plasminogen activator. See brinolytic.
Sulfasalazine $ Aminosalicylate. Dose Maintenance500mg/ 6hPO; Acute–
2g/ 6h PO until remission; PR preparations also available
arthritis, ulcerative colitis, Crohn’s disease
Caution Pregnancy, breastfeeding, renal impairment, G6DP deciency SE GI
Indication Rheumatoid
CI Sulfonamide sensitivity
disturbance, blood disorders, hepatotoxicity, discoloured bodily uids.
Sulfonylureas Dose See Table5.2 Indications Type 2 DM CI Keto-
acidosis
Caution Pregnancy, breastfeeding, hepatic or renal impairment,
porphyria; should not be st- line agents in obese patients as will encourage
further weight gain
hypoglycaemia, hepatic dysfunction, weight gain
SE N+V, diarrhoea, constipation, hyponatraemia,
Info Hypoglycaemia re-
sulting from sulfonylureas can persist for many hours and must always
be treated in hospital; sulfonylureas should not be given on the day of
surgery due to the risk of hypoglycaemia.
Table5.2 Sulfonylureas
Glibenclamide Dose 5mg (2.5– 5mg) 24h PO mane Info Long acting; use
Gliclazide Dose 40– 80mg (40– 60mg) usually 24h PO mane (max
Glipizide Dose 2.5– 5mg (2.5– 5mg) usually 24h PO mane (max
Tolbutamide Dose 0.5– .5g (0.5– 2g) divided throughout the day PO with
cautiously in the elderly
320mg)
Info Medium acting
20mg)
Info Short acting
meals
Info Medium acting
215PHARMACOPOEIA
Symbicort
®
$ Long- acting β2 agonist with corticosteroid. Dose 6–
2micrograms formoterol with 00– 400micrograms budesonide/
2– 24h INH (depends upon inhaler device, see BNF)
(E p. 287), COPD
roidism, TB
SE Fine tremor, nervous tension, headache, palpitation,
Caution Cardiovascular disease, DM, hyperthy-
Indication Asthma
muscle cramps, oral candidiasis, hoarse voice, paradoxical bronchospasm (rare)
Synacthen
Tamiu
InteractionSee salmeterol and uticasone.
®
$ Synthetic corticotropin (ACTH). See tetracosactide.
®
$ Antiviral. See oseltamivir.
Tamoxifen $ Oestrogen receptor antagonist. Dose Breast cancer20mg/ 24h
PO; for other indications consultBNF
breast cancer, anovulatory infertility
Indication Oestrogen receptor- positive
CI Pregnancy Caution Breast feeding, in-
creased risk of thromboembolism, occasional cystic ovarian swellings in premenopausal women
suppression, GI disturbance
Tamsulosin $ α
Benign prostatic hyperplasia
ment
Caution Renal impairmentSE Postural hypotension, headache, dizzi-
ness, urinary incontinence
®
Tazocin
Tegretol
®
SE Hot ushes, vaginal discharge/ bleeding, menstrual
InteractionIncreases eects of warfarin.
antagonist. Dose 400micrograms/ 24h PO Indication
CIBreastfeeding, hypotension, hepatic impair-
InteractionIncreases eects of antihypertensives.
$ Beta- lactam with tazobactam. See piperacillin.
$ Antiepileptic. See carbamazepine.
Teicoplanin $ Glycopeptide antibiotic. See vancomycin.
216 CHAPTER 5 Pharmacopoeia
Temazepam $ Benzodiazepine. Dose 0– 20mg/ 24h PO at bedtime
or preoperative; dependency common (max 4wk course)
Insomnia, preoperative anxiety
noea, unstable myasthenia gravis, hepatic impairment
CI Respiratory depression, sleep ap-
CautionPregnancy,
breastfeeding, history of drug abuse, respiratory disease, muscle weakness, renal impairment
SEDrowsiness, confusion, muscle weakness.
Tenecteplase $ Plasminogen activator. See brinolytic.
Terbutaline $ β
6– 2h NEB; oral preparations are also available, consult BNF
agonist. Dose 500micrograms/ 6h INH; 5– 0mg/
2
Asthma and other reversible airway obstruction, uterine relaxation
during pregnancy
SEFine tremor, nervous tension, headache, palpitation, muscle cramps.
Caution Cardiovascular disease, DM, hyperthyroidism
Tetanus vaccine and immunoglobulin Ep. 459.
Tetracosactide (Synacthen®) $ Synthetic corticotrophin (ACTH).
Dose 250micrograms IV/ IMIndicationDiagnosis of Addison’s disease Caution
Pregnancy, breastfeeding, allergic disorders
osteoporosis
at 30min post Synacthen
InfoBlood should be sampled for cortisol pre- dose and again
®
dose (consult local guidelines).
SE Cushing’s syndrome, DM,
Tetracycline $ Tetracycline antibiotic. Dose 250– 500mg/ 6h PO
IndicationInfection, acne vulgarisCIPregnancy, breastfeeding, renal impairment,
age <2yr (irreversibly stains growing teeth and bones)
gravis may worsen, exacerbates SLE
oesophageal irritation
Interaction Decreased absorption with milk, decreases
SEGI disturbance including, dysphagia/
Caution Myasthenia
eects of oral contraceptive pill, mildly increases eects of warfarin.
Theophylline $ Methylxanthine. Dose 200– 500mg/ 2h PO (de-
pending upon preparation, consult BNF)
COPD (see BTS guidelines)
CIacute porphyriaCautionCardiac disease,
epilepsy, hyperthyroidism, peptic ulcer disease
tion, GI disturbance
Info Theophylline is only available as an oral prepar-
Indication Severe asthma/
SE Tachycardia, palpita-
ation; aminophylline consists of theophylline and ethylenediamine which
simply improves the drug’s solubility allowing IV administration.
Monitoring
theophylline
Thiamine $ VitaminB
24h PO depending on severity (consult BNF);
of ampoules/ 8h IV (Pabrinex
Nutritional deciency, especially alcoholism
2
Toxic >20mg/ L (>0micromol/ L)
Signs of toxicity Arrhythmia, anxiety, tremor, convulsions
2
(E OHAM4 p. 740)
. Dose Oral 25– 00mg/ 24h or 200– 300mg/
®
) (consult local guidelines) Indication
Parenteral 2– 3 pairs
Caution Reports of anaphyl-
axis with parenteral preparations.
Thyroxine $ Thyroid hormone (T
). See levothyroxine.
4
Tinzaparin $ Low- molecular- weight heparin. Dose Depends upon
indication, consult BNF
ment
CI Breastfeeding, bleeding disorders, thrombocytopenia, severe
hypertension, recent trauma
pairment
SE Haemorrhage, thrombocytopenia, hyperkalaemiaInteraction
Indication DVT/ PE prophylaxis and treat-
Caution Hyperkalaemia, hepatic or renal im-
NSAIDs increase bleeding risk, eects increased byGTN.
Indication
Indication
Tiotropium $ Antimuscarinic (anti- M3). Dose 8micrograms/
24h INH; solution for inhalation also available (see BNF)
Maintenance treatment of COPD
Caution Renal impairment, glau-
coma, prostatic hypertrophy, cardiac rhythm disorders
Indication
SE Minimal
antimuscarinic eects.
Tiroban $ Glycoprotein IIb/ IIIa inhibitor. Dose Initially 400nano-
grams/ kg/ min for 30minIV;
48h (max 08h treatment)
gina/ NSTEMI patients
Then00nanograms/ kg/ min IV for at least
Indication Prevention of MI in unstable an-
CI Breastfeeding, abnormal bleeding/ cerebro-
vascular accident within 30d, history of haemorrhagic stroke, severe
hypertension, intracranial disease
Caution Pregnancy, hepatic or renal
impairment, increased risk of bleeding, surgery or major trauma within
3mth
SEBleeding, reversible thrombocytopenia.
Topical corticosteroids Dose Consult BNF; guidance on applying
topical steroids can be found on E p. 76
Indications Inammatory
conditions of the skin, eg eczema, contact dermatitis among
others
CI Untreated bacterial, fungal, or viral skin lesions, rosacea,
perioral dermatitis, widespread plaque psoriasis
CautionUse lowest po-
tency agent possible (Table5.22) for shortest duration of time to limit
side eects
and telangiectasia, acne, depigmentation, hypertrichosis;
adrenal suppression, Cushing’s syndrome
SE Local Thinning of the skin, worsening local infection, striae
Systemic Rarely
Info Topical steroids should
only be commenced after seeking specialist advice (either following a
dermatology review or after consideration by registrar). The decision
to stop potent topical steroids should be taken as seriously— always be
mindful of the potential for a patient to develop an Addison crisis after
stopping long- term potent topical steroids.
Table5.22 Topical corticosteroid potencies
Potency Examples
Mild Hydrocortisone 0.– 2.5%, Dioderm®, Mildison®, Synalar in
Moderately
potent
Potent Beclometasone dipropionate 0.025%, betamethasone
Very potent Clarelux®, Dermovate®, Etrivex®, Nerisone Forte
®
0 dilution
Betnovate- RD®, Eumovate®, Haelan®, Modrasone®, Synalar
in 4 dilution
valerate 0.%, Betacap
Cutivate
Locoid
®
, Ultralanum Plain
®
, Diprosone®, Elocon®, hydrocortisone butyrate,
®
, Locoid Crelo®, Metosyn®, Nerisone®, Synalar
®
®
, Betesil®, Bettamousse®, Betnovate®,
®
®
217PHARMACOPOEIA
Tramadol $ Opioid. Dose 50– 00mg/ 4h PO/ IM/ IV (max 600mg/
24h in divided doses)
Indication Pain CI Acute respiratory depres-
sion, paralytic ileus, raised ICP/ head trauma, comatose patients,
acute porphyria, uncontrolled epilepsy
Caution Pregnancy (especially
delivery), breastfeeding, COPD, asthma, arrhythmias, hepatic or
renal impairment
mouth
InteractionMAOI within 2wkInfoCo- prescribe laxatives if using
SE N+V constipation, respiratory depression, dry
opioids for>24h.
218 CHAPTER 5 Pharmacopoeia
Trimethoprim $ Antibiotic. Dose Acute infection 200mg/ 2h PO;
Prophylaxis 00mg/ 24h PO at night Indication Urinary tract infec-
tions
CI Blood dyscrasias Caution Pregnancy, breastfeeding, renal
impairment, folate deciency
Increases phenytoin levels, increases risk of arrhythmias with
action
SEGI disturbance, rash, hyperkalaemiaInter-
amiodarone.
Valproate $ Antiepileptic. Dose300mg/ 2h PO increasing by 200mg
every 3d (max 2.5g/ 24h in divided doses)
Family history of hepatic dysfunction, acute porphyria
Indication Epilepsy: all forms CI
Caution Pregnancy,
breastfeeding, hepatic or renal impairment, blood disorders (bleeding
risk), SLE, pancreatitis
eects, hepatotoxicity, blood disorders
SEGI disturbance, sedation, headache, cerebellar
Interaction Eects decreased by
antimalarials, antidepressants, antipsychotics, and antiepileptics.
Monitoring
valproate
Trough 350– 700micromol/ L (50– 00mg/ L)
2Toxic >260micromol/ L (>80mg/ L)
ValsartanSee $ AT II antagonists.
Vancomycin $ Glycopeptide antibiotic. Dose25mg/ 6h PO; – .5g/
2h IV; some centres use continuous infusions of vancomycin (consult
local guidelines)
MRSA, antibiotic-associated colitis
Indication Serious Gram +ve infections: endocarditis,
Caution Pregnancy, breastfeeding,
renal impairment, avoid rapid infusion, history of deafness, inammatory
bowel disease
man syndrome)
SENephrotoxicity, ototoxicity, blood disorders, rash (red
InteractionIncreased nephrotoxicity with ciclosporin, in-
creased ototoxicity with loop diuretics.
Monitoring
vancomycin
Usually before 3rd or 4th dose (check local guidelines)
Trough 0– 5mg/ L
2Toxicity can occur within therapeutic range
Venlafaxine $ Serotonin and noradrenaline re- uptake inhibitor. Dose
Initially 37.5mg/ 2h, increase if necessary at intervals of >2wk to 75mg/
2h (max 375mg per 24h)
iety disorder
CI Breastfeeding, high risk of cardiac arrhythmia, uncon-
trolled hypertension
heart disease, epilepsy, history of mania, glaucoma
hypertension, palpitation, dizziness, drowsiness
IndicationMajor depression, generalized anx-
Caution Pregnancy, hepatic or renal impairment,
SE GI disturbance,
InteractionMAOIs within
2wk, increased risk of bleeding with aspirin/ NSAIDs, CNS toxicity with
selegiline, mildly increases eects of warfarin.
Ventolin
®
$ β2 agonist. See salbutamol.
VerapamilSee $ Calcium- channel blockers.
Vitamin KSee $ Phytomenadione.
Warfarin $ Coumarin. Dose Loading Ep. 430; Maintenance Typically
– 5mg/ 24h PO dictated by the patient’s INR (though higher doses and
dosing on alternative days are not uncommon)
IndicationProphylaxis of
thromboembolism (atrial brillation, mechanical heart valves, etc), treatment of venous thrombosis or pulmonary embolism
ulcers, severe hypertension, bacterial endocarditis
CIPregnancy, peptic
CautionBreastfeeding,
hepatic or renal impairment, conditions in which risk of bleeding is increased (eg GI bleeding, peptic ulcer, recent surgery, recent ischaemic
stroke, postpartum, bacterial endocarditis), uncontrolled hypertension
recent
SE Haemorrhage, rash, alopeciaInteraction Avoid cranberry juice
(ianticoagulant eect)
Info Warfarin is available in tablets of 0.5mg
(white), mg (brown), 3mg (blue), and 5mg (pink) but check which tablets are stocked locally.
Zolpidem $ Non- benzodiazepine hypnotic. Dose 0mg/ 24h PO at
night
Indication Short- term treatment of insomnia CI Breastfeeding, se-
vere hepatic impairment, psychotic illness, neuromuscular respiratory
weakness, unstable myasthenia gravis, respiratory failure, sleep apnoea
CautionPregnancy, hepatic or renal impairment, muscle weakness,
history of drug abuse
SE Taste disturbance, GI disturbance, headache.
Zopiclone $ Non- benzodiazepine hypnotic. Dose3.75– 7.5mg/ 24h PO
at night
Indication Short- term treatment of insomniaCI Breastfeeding,
severe hepatic impairment, neuromuscular respiratory weakness, unstable myasthenia gravis, respiratory failure, sleep apnoea
Caution
Pregnancy, hepatic or renal impairment, muscle weakness, history of
drug abuse
Zoton
Zyban
SE Taste disturbance, GI disturbance, headache.
®
$ Proton pump inhibitor. See lansoprazole.
®
$ Treatment of nicotine dependence. See bupropion.
219PHARMACOPOEIA
Chapter6
Resuscitation
Early warning scores 222
Intensive care 224
2Peri- arrest 226
2In- hospital resuscitation 227
2Advanced Life Support (ALS) 228
2Arrest equipment and tests 230
2Advanced Trauma Life Support (ATLS) 232
2Paediatric Basic Life Support 234
2Choking 237
2Newborn Life Support (NLS) 238
2Obstetric arrest 240
221
222 CHAPTER6 Resuscitation
Early warningscores
$ Since its original release in 202, the National Early Warning Score
(NEWS) has been widely implemented as a tool to facilitate the early detection of the deteriorating patient and standardize the clinical response.
An updated version (NEWS2) was released in 207
Use on the wards Scoring of these physical parameters is usually
undertaken by nursing sta when documenting patients’ observations.
Normal observations are awarded a score of 0, while abnormal observations attract higher scores. The values for each physical parameter are
added together to give an aggregate score, on which the clinical response
is based.
The clinical response This depends on the overall score awarded
(Table 6.). A NEWS2 score of ≥5 is generally given as the urgent response threshold. In practice, as the doctor on-call, you will be asked
to urgently review patients with a NEWS2 score ≥5 and your senior
(usually a registrar) should be involved in the emergency assessment of
patients with a score ≥7.
Common pitfalls Often the trend in a patient’s vital signs and NEWS2
score is more relevant than their absolute number. A stable patient with
a NEWS2 score of 8 may not require any urgent action, whereas a patient whose score has increased from 0 to 5 may be heading towards
peri-arrest. Never disregard your gut feelings or those of your colleagues
simply because the overall score is low. Bear in mind that the NEWS2
score does not take into account increasing oxygen requirements, it is always worth clarifying this when deciding how urgently to respond.
Table6. The clinical response to a NEWS2 score
NEWS2
score
0 Min 2hrly Continue routine monitoring
–4 Min 4–6hrly Registered nurse to assess patient
3 in a single
parameter
≥5
≥7
Frequency of
monitoring
Min hrly Registered nurse to inform medical team caring
Min hrly Registered nurse to immediately inform and
Continuous
monitoring of
vital signs
Clinical response
for patient who should review and decide
whether escalation of care is necessary
request urgent assessment by a clinician or
team competent in the care of acutely ill
patients. Clinical care to be provided in an
environment with monitoring facilities
Registered nurse to immediately inform
specialist registrar (or above) and request
emergency assessment by a team with critical
care competencies. Consider transfer to a
critical care facility
1
(Fig. 6., Box 6.).
Mhttps://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 See also
NICE guidelines at Mwww.nice.org.uk/guidance/cg50