Commonly Used Drugs In Cath Lab
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Transcript of Commonly Used Drugs In Cath Lab
Cardiac catheterization laboratory is a lab in a hospital where different types of cardiac procedure are performed routinely.
Common procedure includes: Coronary angiogram, Percutaneous coronary intervention, Peripheral angiogram, PTMC, TPM,PPM implantation, Right & left heart cahteterization, Carotid angiogram, Aortogram, LV graphy,RV graphy etc.
Different drugs are used in different time of
procedure.
Those drugs have many other indications,
mechanism of action and adverse effects.
Here commonly used drugs are discussed
briefly with main focus on their use in cath
lab.
Class Ib antiarrhythmic drug.
Fast Na+ channel blocker with shortening of
action potential.
Indicated in ventricular arrythmias,
sympathetic & different types of peripheral
nerve block, regional & surface
anesthesia,painful haemorrhoides etc.
Mainly used as local anesthetic agent in
cath lab.
1% (10mg/ml) Injection is ideal.
Here 2% Injection is used.
50ml vial; 1ml contains 20mg lidocaine.
12-15 ml Injection is instilled at and around the approach area.
In ventricular arrythmias eg. Resistant VT,VF,
50-100mg (2.5-5ml) IV bolus within 2 minutes followed by a maintenance dose of 12 ml/hr in first ½ hour, 9ml/hr for next 2 hrs & then 6 ml/hr for 24-48 hrs.
Adverse effects:
Dizziness, Drowsiness,Confusion, Respiratory
depression,Convulsion,Anaphylaxis.
Hypotension,Bradycardia & Cardiac arrest.
Anticoagulant or anti thrombotic drug used for rapid anticoagulation.
Unfractionated heparin (UFH) & Low molecular weight heparin (LMWH) are commonly used clinically.
In cath lab UFH is mainly used.
UFH has more anti-thrombin (IIa) activity ,it also inhibits Xa, XIa & other factors associated with intrinsic coagulation pathway. Thus inhibits thrombin induced platelet aggregation.
Used during primary or elective PCI, in
different thromboembolism, Pulmonary
embolism, DVT, Peripheral arterial
embolism/PVD, Cardiopulmonary bypass
etc.
5ml vial, 1ml contains 5000 IU heparin.
Dose in most cases: 100 IU/kg ie. 1ml IV stat
followed by 1000 IU/hr for 24 hour.
In Cath lab,1ml heparin is diluted with
500ml NS in a bowl.
This hepainized saline is used for
washing/flushing of insturments,
intracoronary flushing after giving
intracoronary Heparin,GTN or Eptifibatide.
0.5ml heparin is diluted with 2ml NS in a
syringe; Given in intracoronary route after
vascular access sheath is fixed.
During PCI, 2 ml (10000 IU) heparin is given
after passing of PTCA guidewire.
Adverse effects:
Heparin induced thrombocytopenia and
thrombosis syndrome (HITTS), bleeding,
bruising,epistaxis,hematoma,hypersensitvity
raction ,nausea,vomiting,constipation,
osteoporosis,alopecia etc.
Organic nitrate which is converted to
NO,that stimulate guanylate ccyclase
enzyme which in turns synthesize cGMP,
eventually resulting dephosphorylation of
myosin light chain of vascular smooth
muscle fibre. Subsequet Ca++ release
causes smooth muscle relaxation &
vasodilatation.
Dilates both vascular bed with venous
predominant effect.
Decreases both preload & afterload,also
reduces both systolic & diastolic BP.
Used as vasodilator & anti-antiginal drug in
effort angina,UA,CSA,NSTEMI,hyprtensive
crisis etc.
Has oral tablet,sublingual spray,IV infusion
form.
10 ml ampoule; 1ml contains 5mg (5000 µg)
GTN.
For IV infusion, 1amp mixed with 40ml 5%
DA & infuse @ 5 µg/min or 0.3ml/hr. Can be
increased by 0.3ml/hr every 10 min.
Max dose 200-250 µg/min (12-15 ml/hr).
In cath lab,0.2 ml (1000 µg)dissolved with
9.8 ml NS from where 1ml solution is taken in
each several syringe.
1ml dissolved GTN is given after PTCA
balloon inflation to dilated the blood
vessels during PCI. Several injections may
be needed accordingly.
Side effects:
Hypotension, headache,facial flushing,light
headedness,syncope,tachycardia,methe
moglinemia,nitrate tolerance etc.
Contraindications:
Acute Inferior MI with RV involvement,
HOCM, Use of Sildenafil or related
drugs,cardiac tamponade or constrictive
pericarditis etc
Gp IIb/IIIa Inhibitor (Anti-platelet drug)
Abciximab, Eptifibatide & Tirofiban are so
far used drugs. Eptifibatide is most
commonly used. All are IV form.
These drugs inhibit one of the platelet
integrin adhesion receptors technically
known as the αIIβ3 receptor. Thus they
block the final step of platelet activation &
cross linking by fibrinogen & vWF.
Indicated in primary or elective PCI,
UA/Non-STEMI with plan of invasive
strategy.
100ml vial, 1ml contains 0.75 mg
eptifibatide INN.
Dose is 180 mcg/kg IV bolus ( A second
dose is given 10 minutes after first dose )
followed by maintenance dose of 2
mcg/kg/min.
Infusion should continue until hospital
discharge or initiation of CABG, upto 72
hours.
In case of renal impairement ( CrCl <
50ml/min) maintenance dose may
reduced to 0.5-1 mcg/kg/min.
In our center during PCI,5-10 ml eptifibatide
is given slowly via intracoronary route
followed by heparinized saline flush.
Adverse effects:
Bleeding including ICH, pulmonary/GI
hemorrhage, thrombocytopenia,
hypotension, hypersensitivity reaction.
Several anti-platelet drugs are used in cath
lab namely clopidogrel & prasugrel.
Clopidogrel:
ADP receptor antagonist. It irreversibly
inhibit P2Y12 platelet receptor, thereby
prevents P2Y12 induced Gp IIb/IIIa
activation which is essential for platelet
aggregation.
Available as 75mg oral tablet.
Indicated in ACS,CVD,PVD for reduction of
atherosclerotic/thromboembolic events.
Usual dose is 75 mg daily but in case of
ACS with or without PCI and also before
PCI 300mg loading dose is indicated.
For prevention of post-stent thrombosis,
continue 75mg daily for at least 12 months.
Adverse effects include bleeding,
neutropenia, GI upset, Gastric irritation,URTI
etc
Prasugrel:
It is a novel third generation ADP receptor
blocker, irreversibly inhibit the P2Y12
receptor at the same site of clopidogrel.
But it has enhanced hepatic conversion to
the active form & is about 5-9 times more
potent than clopidogrel achieving greater
platelet inhibition than 600mg of
clopidogrel.
Available as 5mg & 10mg oral tablet.
Indicated in acute coronary syndrome, patients undergoing PCI, prevention of thromboembolic events including stent thrombosis,CVD.
Usual dose is 10 mg daily, in case of PCI preparation 60mg loading dose is indicated.
Caution should be taken in case of old age (>75 years) & low body weight (<60kg) because of the increased chance of bleeding.
Adverse effects include bleeding, TTP,
anaemia, hypertension, hypotension, atrial
fibrillation, bradycardia, GI upset,
headache,back pain, rash, peripheral
edema etc.
An inotrope is an agent that alters the
energy or force of muscular contraction.
Positive inotropes increase the force of
contraction whereas negative agents
decrease it.
Commonly used positive inotropes include
dopamine,dobutamine,adrenaline,nor
adrenaline,isoprenaline,digitalis etc.
Metoprolol,bisoprolol,carvedilol,verapamil,
diltiazem ,quinidine are few examples of
negative inotropes.
Catecholamine like agent, the precursor of
noradrenaline & releases nor epinephrine
from the stores of nerve endings in the
heart. In the periphery is overridden by
dopaminergic DA2 receptor causing
vasodilatation .
Dopamine stimulates the heart by both β1
and β2 adrenergic response.
Low dose mainly stimulates dopaminergic
receptors producing renal & mesenteric
vasodilatation.
Higher dose stimulates both β1 & β2
receptors along with dopaminergic
receptors causing heart stimulation & renal
vasodilatation.
Large dose stimulates α receptor causing
vasoconstriction.
Indicated in cardiogenic shock in coronary
artery disease or cardiac surgery, acute
heart faliure,hypotension etc
Dose:
5ml ampoule, 1ml = 40 mg dopamine
Renal: 2-5 mcg/kg/min
Cardiac: 5-10 mcg/kg/min
Vasoconstriction: 10-20 mcg/kg/min
Side effects:
Tachycardia, nausea, vomiting,
hypertension, anginal pain, ectopic beats
etc.
Synthetic analogue of dopamine which
stimulate β1>β2>α which gives potent
inotropic effect.
Due to β2 stimulation often there is fall of
diastolic blood pressure and hypotension.
So it is logical to use it simultaneous with
dopamine.
Indicated in acute on chronic refractory
heart failure, severe acute myocardial
faliure following AMI or cardiac surgery,
cardiogenic shock, excessive β blockade.
Dose:
5ml vial contains 250mg dobutamine.
2-15 mcg/kg/min
Renal: 1.5 ml/hr
Cardiac: 3ml/hr
Vasoconstriction: 6ml/hr
Side-effects:
Tachycardia, PVCs, HTN, dyspnoea, chest
pain, headache, nausea etc.
Class III anti-arrhythmic drug, prolongs cardiac action potential. It increases the refractory period in SA & AV node, slows the intra-cardiac conduction. It has also class Ia, II & IV anti-arrhythmic properties.
Has structural similarity with thyroxine as a 200mg tablet contains 75mg of Iodine.
As it has a low incidence of pro-arrhythmic effect, it is indicated both in acute life threatening arrhythmia as well as chronic arrhythmia suppression.
It is useful both in supraventricular and
ventricular arrhythmias.
Available in 100mg, 200mg oral tablet and
3ml IV injection .
Dose:
1 ampoule(150mg) IV bolus followed by a
maintenance dose of 3ml/hr in first 6 hours
& 1.5ml/hr in next 18 hours.
Adverse effects:
Pulmonary fibrosis, DPLD, Hypo /
hyperthyroidism, corneal micro deposits.
Elevated liver enzymes, jaundice, hepatitis,
hepatomegaly, peripheral neuropathy,
epididymitis, gynaecomastia etc.
Adenosine:
Mainly used in SVT
Dose: 1 amp (2ml/6mg) IV bolus followed
by a saline flash, repeat several doses
every 1-2 mins if no response.
Atropine:
Used in severe bradycardia
Dose: 1-2 amp (0.6-1.2 mg) every 3-10 mins
upto 5 amp to achieve HR at least 60/min.
Furosemide:
In cath lab, used to treat pulmonary
edema.
Dose: 0.5-1mg/kg (or 40mg) IV bolus over 1-
2 mins, may be increase upto 80mg if no
response.
For continuous infusion: 5 amp in 40ml NS @
2.5ml/hr
Diazepam:
For restless/anxious patient
Hydrocortisone:
1-2 vial (100-200mg) IV stat when patient is
shivering or suspected dye reaction.
Pantoprazole:
Potent proton pump inhibitor, less drug
interaction, so cardiac friendly.
Usually 1 vial (40mg) IV is given prior to PCI.
Povidone Iodine:
Iodine based broad spectrum antiseptic
solution used for antiseptic wash of
operative area.
Iohexol:
Iodine based non-ionic & low osmolalitycontrast agent helps to visualize coronary arteries & cardiac chambers clearly.
It is clear & colorless agent, excreted totally via kidney in almost unchanged form, so caution should be made in case of renal impairement patient.
100ml bottle/vial contains 350mg of iodine per ml.
50-150 ml solution is usually needed according to procedure variation.