Munzur Morshed, Pharm D. candidate 2011Arnold & Marie Schwartz College of Pharmacy and Health Sciences

North Shore- Long Island Jewish Health SystemInfectious Diseases-Advanced Pharmacy Practice

Pharmacotherapy of Septic Shock

Case PresentationIMA is a 59 Y/O female, who recently had a left urethral stent placed in her left ureter two weeks ago, came to

the emergency room complaining of left-sided flank pain for 1-2 days. Patient was noted to have vomiting for oneday, with symptoms of headache, and anxiety. Patient had no hx. of URI, possible kidney stone is suspected. Patient was admitted to the ICU with septic shock secondary to left pyelonephritis, hypoxia and HOTN. Her BPdid not respond to the fluids given in the ER. Patient is currently intubated and is monitored on the ventilator. Past Medical/Surgical history: Patient had a left urethral stent placed a few weeks Family Hx: Patient has a family history of DM and CAD.

Allg: NKA

Meds on admission:IV Norepinephrine 2MG/250mL;Normal Saline 1000 ML; Lovenox 40MG SQ QD; Primaxin 500MG IVPB Q6H, Flagyl 1500 mg IVPB q6H STAT, Merrem 500mg IVPB Q8H, Regular Insulin Sliding Scale, Sodium Bicarb 7.5% 44.6MEQ, Gentamicin 100 MG IVPB one/time STAT, Protonix IVPB 40 mg PO q6h; Tylenol with Codeine #3 -1T PO Q4H PRN

PE: Temp 102.6, Pulse 114, RR 18, BP 79/50,

Laboratory Findings: WBC 20.6, Hg 8.5, Na 131, K 2.6, Cl 2.6, CO2 24, BUN 17, Scr 1.5, Glucose 217, Ca 6.5,

Lactate 5.2, AST/ALT 61/91, MAP 59.67, PH 7.19, HCO3 17

Urinalysis: Protein 150, Blood Urine- Large, Leuko Ester- Moderate, Nitrites (+), WBC 10-25, Bacteria-manyMicrobiology Blood Culture: Gram (-) Rods in aerobic Bottle. Urine Culture: Greater than 100,000 CFU/ML Pseudomona Less than 10,000 CFU/ML of other organismDiagnosis: Septic Shock and Pyelonephritis secondary to Stent placement

Introduction

What is shock? Life threatening state, decrease in tissue perfusion of

blood supply Characterized by lack of nutrient and O2 rich blood to the

organs resulting in inadequate perfusion Vital Signs

HR < 20 or > 150 bpm SBP < 80 mmHg, decrease by at least 40mmHg MAP < 60 mmHg DBP > 120 mmHg RR > 35 breaths/min pH < 7.1 or >7.7

low urine output (<0.5ml/kg/hr ) and confusion or loss of consciousness

Types of Shock

Hypovolemic Shock Loss of blood volume (plasma

+ RBCs)▪ External-surgery or trauma▪ Internal-GI bleeding

Cardiogenic Shock Hearts inability to pump

appropriate amount of blood Decreased Cardiac Output

Septic Shock- Discussed in detail

Obstructive Shock Subtype of Hypovolemic

Shock Increase pressure of the

jugular vein distended jugular vein

Neurogenic Shock Injury of the spine Loss of cardiac nerve fibers

from the sympathetic nerve fibers at T1-T4 resulting in profound bradycardia

Diaphoretic Skin Anaphylactic Shock

Angioedema like reaction Large Eruptions or bumpy

skin Edema, Massive Swelling Constricted Airways; Swollen

throat; Breathlessness and cough

Weak or rapid pulse

What is Septic Shock?

Massive Systemic infection associated with arterial hypotension that is refractory to fluid resuscitation

It is a systemic inflammatory Response syndrome Criteria must include the following (2 out of 4)▪ WBC >12K or <4K or >10% bands▪ Temperature > 38C or < 36C▪ Heart rate > 90bpm▪ Respiratory Rate > 22 breaths/min▪ PaCO2 < 32mmHg

Systemic Infection- Any etiology Bacterial- Presence of Bacteria in the bloodstream Fungemia- Presence of Fungus in the Bloodstream

Epidemiology

Defined by site of infection Respiratory Tract (21%-68%) Intraabdominal Space (14%-22%) Urinary Tract (14%-18%)

Pathogens Gram-Positive bacteria (40% of patients) Gram-Negative bacteria (38% of patients) Fungi (17%)

Pathogens

GRAM-POSITIVE BACTERIAL SEPSIS

Most predominant in Septic Shock Staph. Aureus Strep. Pneumoniae Coagulase-Negative

Staphylococci Enterococcus

Strep. Pneumoniae- Mortality rate of more than 25%

Staph. Epidermidis- related to infected intravascular device

GRAM-NEGATIVE BACTERIAL SEPSIS

Severity depends on underlying comorbidites▪ Fatal Prognosis▪ Acute Leukemia▪ Aplastic Anemia▪ Burn Injury- >70& BSA

▪ Non-fatal prognosis▪ Diabetes Mellitus▪ Chronic Renal Insufficiencies

Most predominant▪ Escherichia coli▪ Pseudomonas aeruginosis

Pathogens Cont…

ANAEROBES AND MISCELLANEOUS BACTERIAL SEPSIS

Low risk organism but can occur

Usually seen with other common pathogens in sepsis

Meningococci, gonococci, rickettsiae, chlamydiae, spirochetes

FUNGAL SEPSIS

Rate of the infection doubled since the 2000

Most Common pathogens▪ Candida Albicans ( Most Dominant)▪ Candida Glabrata▪ Candida Tarapsilosis ▪ Candida Tropicalis▪ Candida Krusei

Risk factors of fungal-sepsis▪ Abdominal Surgery▪ Poorly controlled Diabetes Mellitus▪ Broad-spectrum Antimicrobials▪ Corticosteroids▪ Foley▪ Central Venous Catheter

Pathophysiology

Clinical PresentationEarly Sepsis Late Sepsis

Fever or hypothermia Lactic acidosis

Rigors, chills Oliguria

Tachycardia Leukopenia

Tachypnea-RR > 35 Disseminated Intravascular Coagulation

Nausea, vomiting Myocardial Depression

Hyperglycemia Pulmonary Edema

Myalgias Hypotension

Lethargy, malaise Hypoglycemia

Proteinuria Thrombocytopenia

Hypoxia- o2< 50 Acute Respiratory Distress Syndrome

Leukocytosis GI Bleeding

Hyperbilirubinemia Coma

Prognosis

Increase mortality rate in a step-wise approach SIRSSepsisSevere Sepsis Septic Shock

Higher mortality rates with co-morbidities Advanced age COPD HIV Pseudomonas Infection Failing Organs▪ Ex. From 2 to 4 organs Increase mortality from 54% to

100%.Elevated serum Lactate->4 mmol/L- Increase

mortality as high as 89%

Goals of therapy

Identify the source of infection. Control the source of infection Eradicate the infection Provide adequate hemodynamic support and

tissue perfusion Prevent continued organ failure,

complications, and/or mortality Provide supportive care during the length of

stay in the ICU

Therapeutic Alternatives

Interventions/therapies-Must be accomplished within the first 6 hours Cultures Antibiotics within 1 hour Measure a serum lactate Achieve a CVP = 8-12 mmHg MAP > 65 mmHg Maintain urine output ≥0.5 mL/kg/hr Achieve a ScvO2 ≥70%

Diagnosis and Identification of Pathogens

Determine the source of the infection Systemic Complication Recent Travel history Animal Exposure Use of antimicrobials

Two sets of Blood samples Peripheral Vein- Culture in an aerobic and an-aerobic environment

Cather-related suspecting Two sets of blood culture▪ Catheter Hub▪ Peripheral Vein

Abdominal infections- Fluid Collections by imaging studies Lumbar Puncture- in cases of mental alteration, severe

headache, or a seizure

Hemodynamic Monitoring

Mean Arterial Pressure(MAP)- Systemic Vascular Resistance x Cardiac Output MAP greater than 50mmHG-Goal MAP less than 50 decrease coronary and cerebral blood flow Monitor Continuously- Arterial Catheter in the Radial Artery

Central Venous Catheter Placed in 3 veins-Triple Lumen▪ Internal Jugular Vein-Neck▪ Subclavian Vein- Chest▪ Femoral Vein- Groin

Measures the central venous oxygen saturation- ScvO2, Central Venous Pressure (CVP)

Goal CVP = 8-12 mmHg during fluid resuscitation Goal CVP = 12-15mmHg-in presence of mechanical

ventilation

Hemodynamic Monitoring cont…

Central Venous Catheters Depends on CO, Oxygen demand, SaO2 and

Hemoglobin Goal SaO2 = >70% in shock Lower Value Inadequate O2 oxygen delivery

to tissue and high extraction by tissueLactate

Metabolic product of Pyruvate increase production in anaerobic conditions

Goal= 0.5 – 2.2 mmol/L Better correlation with outcomes

Treatment Recommendations

Antibiotic Therapy

Broad Spectrum antimicrobials against all likely pathogens

Fluids Crystalloids vs. Colloids

Vasopressors Norepinephrine, Dopamine, Epinephrine, Phenylephrine

Ionotropes Dobutamine

Glucose Control

Regular Insulin therapy

Steroids Hydrocortisone, Fludrocortisone

Drotrecogin Recombinant Human Activated Protein C (Xigris)

DVT Prophylaxis

UFH, LMWH, Fondaparinux, Graduated Compression Stockings, Intermittent pneumatic Compression

Stress Ulcer Prophylaxis

Proton Pump inhibitors, Histamine-2 Receptor antagonists, Sucralfate

Antimicrobial Therapy  Empiric parenteral aggressive antimicrobial

therapy is a MUST Selection of the antimicrobial depends on

Suspected site of infection The most likely pathogens Community acquired or Hospital Acquired Immune status of the patient Institution susceptibility profile of the ABX

Re-asses the regimen 48-72 hours laterSwitch to narrow spectrum based on culture and susceptibility

Cases of Pseudomonas, Neutropenia, severe sepsis - Combination therapy is imminent

Empiric Antimicrobial Therapy

Infection Site Antimicrobial Regimen

Community Acquired

Hospital Acquired

Urinary Tract Ciprofloxacin or levofloxacin

Ciprofloxacin, levofloxacin or ceftazidime, ceftriaxone

± gentamicin

Respiratory Tract

Levofloxacin, moxifloxacin,

gemifloxacin or ceftriaxone +

clarithromycin/azithromycin

Piperacillin, ceftazidime, or

cefepime

+ gentamicin or

ciprofloxacin

Intrabdominal Zosyn, Unsyn, or ciprofloxacin

+ metronidazole

Piperacillin/tazobactam or carbapenem

Empiric Antimicrobial Therapy

Infection Site Antimicrobial Regimen

Community Acquired

Hospital Acquired

Skin/soft tissue Ciprofloxacin or levofloxacin

Zosyn, Unsyn or clindamycin plus ciprofloxacinor carbapenem

Catheter-related Vancomycin + gentamicin

Unknown Piperacillin or ceftazidime/cefepime or imipenem/meropenem

± vancomycin

Antifungal Therapy

Choice of therapy depends upon Fungal Species Presence of Liver and Kidney dysfunction-Elimination Prior Exposure to anti-fungal agents

Treatment of Choice- Amphotericin B based preparations Fluconazole, Itraconazole Fluconazole plus Amphotericin B Voriconazole- Fluconazole resistant isolates Caspofungin- Potent against all Candida Species

Initial Empiric Therapy- parenteral amphotericin B or caspofungin▪ Better activity against Resistant fungal speicies, non-

albicans; neutropenic and critically-ill patients

Duration of Therapy

Variable- Site of infectionNeutropenic- continue therapy until

afebrile for 72 hours and no longer neutropenic

Normal host with sepsis- 7 to 10 daysHost with Fungal infection- 10 to 14 daysStep-Down from parenteral to oral

therapy Hemodynamically Stable Afebrile for 48 to 72 hours Normal WBC count Able to take PO medications

Fluids

Significant Fluid Requirements due to Peripheral Vasodilation Capillary Leakage

Mechanism of action Increasing left ventricular preload maximize

cardiac output restore tissue perfusion decrease in serum lactate level

Titrate over time based on mental status,HR, BP, UOP

Choice of Agents Crystalloids vs. Colloids

Fluids cont…

Intravenous Fluids Dextrose- Not a crystalloid, used for

uncomplicated dehydration caused by water deficit

Crystalloids▪ Freely cross the semi-permeable membrane and

form crystals Colloids▪ Increased molecular weight= Increased retention

time▪ Cannot pass through the semi-permeable

membrane▪ Eventually will leak through the membrane (e.g.

60% of albumin shifts to interstitium by day 3-5)

Crystalloids vs. Colloids

Category Crystalloids Colloids

Examples 0.9% Normal Saline, Lactated Ringers solution

5% albumin, 6% Hetastarch

Capillary membrane Permeability

Freely cross Impermeable

Intravascular Volume Requirement

250mL per 1000mL given

1000mL per 1000mL given

Volume needed to fluid challenge

Large (500-1000mL)

Small (300-500mL)

Duration of action Short, 0.5-1 hour Long, > 2-4 hours

Cost Inexpensive Expensive

Crystalloids vs. Colloids Cont…

Crystalloids Colloids

10L per 24 hour period Rapid Restoration of intravascular volume

25%-intravascular; 75% Extravascular

Greater intravascular volume expansion

Higher volume required Less volume required

More peripheral edema Less peripheral edema

Saline Vs. Albumin Fluid Evaluation (SAFE study)-No clinical significance between the agent

Inotropes

Improves Cardiac OutputMust be on board if failed therapy with

fluids Increase risk of atrial, ventricular

arrhythmias Increases demand of Myocardial O2 in

pt.s with CAD-Caution.DobutamineMilrinone, Nesiritide- Not used in Septic

Shock

Inotropes cont…

Dobutamine b-adrenergic inotropic agent 1 > 2 b b ≥ 1a Vasodilatation due to stimulation of the Beta

receptor Can be an add on to nor-epinephrine in sepsis 2.5-5 mcg/kg/min

Vasopressors

Must be on board if failed therapy with fluids

Considered when Systolic BP < 90mmHg, MAP <60-65mmHg

Titrate slowly to achieve MAP w/o impairing SV

Norepinephrine, Dopamine, Epinephrine, Phenylephrine

Vasopressors cont…

Norepinephrine(Levophed) First line agent for septic shock Stimulates a1,2 > b1 Increases MAP by vasoconstriction on

peripheral vascular beds

Vasopressors cont…

Dopamine Activity against D1,2,a1 and b2 activity-Dose

related 1-3 mcg/kg/min-D1,2▪ For treatment or prevention of AKI

3-10 mcg/kg/min- D1, b1 >10-20 mcg/kg/min- a1, b1▪ Vasoconstriction AND increase MAP

May depress ventilation, worsen hypoxemia, inhibit GH secretion and T-Cell proliferation

Vasopressors cont…

Epinephrine (Adrenaline) nonspecific a and b-adrenergic agonist significant peripheral vasoconstriction- Last

line therapy for refractory shock 1-10 mcg/min

Phenylephrine (Neosynephrine) selective a1-agonist Rapid onset, short duration, and primary

vascular effects, and it is least likely to produce tachycardia

Limitted use- preferred in tachyarrhythmia

Tight Glucose Control

Intensive Insulin Therapy Hyperglycemia causes phagocyte

dysfunction, worsens ischemia, increases platelet activation, increases production of pro-inflammatory cytokines (Il-6, TNF-a)

Target Goal- <140-180mg/dL (NICE SUGAR study)

Desired Goal- < 150 mg/dL Regular Insulin 100 units in 100ml NS, start at

3 units/hr, check FSBS q1hr

Corticosteroids

Indications Diagnosis of Critical Illness related

corticosterioid insufficiency ▪ Random Cortisol < 10mcg/dL▪ D Total serum Cortisol <9mcg/dL

Refractory Septic Shock▪ SBP <90mmHg for >1 hour despite fluid

resuscitation, inotropes, vasopressors▪ Hydrocortisone 200-300 mg/day IV divided q6-q8h

± fludrocortisones 50mcg PO daily x 7 days

Drotrecogin Recombinant Human Activated Protein C

(rhAPC) Inhibits Coagulation, reduces inflammation Clinical Trial- Recombinant Human Activated Protein

C Worldwide Evaluation in Severe Sepsis (PROWESS)▪ Reduced Mortality by 24.7% in those who received rhAPC

Current recommendations APACHE II score ≥25, sepsis-induced multiple organ

failure, septic shock, or Sepsis-induced ARDS and with no absolute

contraindication related to bleeding risk Recommend avoid rhAPC if APACHE II < 20 or one

organ failure 

DVT Prophylaxis

Pharmacologic Approach Unfractionated Heparin Low Molecular Weight Heparin Fondaparinux▪ Avoid if kidney function is impaired

Non-Pharmacologic Approach if high risk for bleeding▪ Graduated Compression Stockings (GCS)▪ Intermittent Pneumatic Compression (IPC)

DVT Prophylaxis

Patient Considerations UFH or LMWH preferred first-line▪ Consider LMWH for highest risk▪ E.g. Spinal Cord Injury, Trauma, Surgery

Consider GCS or IPCs if C/I to pharmacologic prophylaxis

Severe Risk- E.g.- Shock, Septic▪ UFH or LMWH + GCS or IPC

Stress-Ulcer Prophylaxis Pharmacologic Approach

Proton Pump Inhibitors (PPIs)▪ Greater acid-suppression (less evidence)▪ First line for patients with upper GI bleed

Histamine-2 receptor antagonists (H2RAs)▪ Most Evidence

Sucralfate-Sucrose octasulfate, Aluminum Hydroxide Patient Considerations

Thrombocytopenia- Consider PPI▪ More gastric acid suppression may lead to Clostridium

Difficile- associated diarrhea, pneumonia▪ PPIs are the most common cause of interstitial nephritis

Sucralfate may clog feeding tubes 

Management Early goal directed therapy

Reach the following endpoints w/in 6 hours of onset▪ CVP=8-12mmHg, (or 12-15 if mechanically ventilated)▪ MAP ≥65mmHg, UOP ≥0.5mL/kg/hr▪ ScvO2 >70%

Fluid challenges with crystalloids 1000mL or colloids 300-500mL over 30 min▪ Target CVP= 8-12mmHg or (12-15 if mechanically ventilated)

Begin Broad-Spectrum ABX w/in 1 hour Consider most likely pathogens and fungal infections

based on suspected source of infection Skin and Soft tissue Intra-Abdominal Respiratory Urinary Tract

Management cont… Vasopressors to maintain MAP ≥ 65mmHg

Administer centrally NE or DA are first line▪ NE-1st line▪ Phenylephrine, Epinephrine, Vasopressin- Last line

Use epinephrine if blood pressure unresponsive to first line Do not use low dose DA for renal protection

If ScvO2 target not reached with fluids, transfuse packed RBCs to hematocrit ≥ 30% and/or dobutamine infusion

Corticosteroids Refractory Septic Shock SBP <90mmHg for >1 hour despite fluid resuscitation,

vasopressors

Management Cont…

rhAPC Use if APACHE II ≥ 25 or multiple sepsis-

induced organ failure if no C/I Avoid if APACHE II <20 or one organ failure

Analgesia, sedation protocols titrated to predetermined endpoints

DVT prophylaxis with UFH and LMWHHead of the bed elevation >30-45 degree

angleSUP with PPI or H2RAGlycemic control with intensive insulin

therapy

Conclusion Septic Shock- Systemic Infection of any etiology\ It is a goal directed therapy Must Achieve the following parameters within the

first 6 hours Measured Serum Lactate CVP= 8-12mmHg MAP > 65mmHg urine output ≥0.5 mL/kg/hr ScvO2 ≥70%

Provide Supportive therapy Treat the systemic infection Monitor closely for efficacy and toxicity

Case PresentationIMA is a 59 Y/O female, who recently had a left urethral stent placed in her left ureter two weeks ago, came to

the emergency room complaining of left-sided flank pain for 1-2 days. Patient was noted to have vomiting for oneday, with symptoms of headache, and anxiety. Patient had no hx. of URI, possible kidney stone is suspected. Patient was admitted to the ICU with septic shock secondary to left pyelonephritis, hypoxia and HOTN. Her BPdid not respond to the fluids given in the ER. Patient is currently intubated and is monitored on the ventilator.

Past Medical/Surgical history: Patient had a left urethral stent placed a few weeks Family Hx: Patient has a family history of DM and CAD.

Allg: NKA

Meds on admission:IV Norepinephrine 2MG/250mL;Normal Saline 1000 ML; Lovenox 40MG SQ QD; Primaxin 500MG IVPB Q6H, Flagyl 1500 mg IVPB q6H STAT, Merrem 500mg IVPB Q8H, Regular Insulin Sliding Scale, Sodium Bicarb 7.5% 44.6MEQ, Gentamicin 100 MG IVPB one/time STAT, Protonix IVPB 40 mg PO q6h; Tylenol with Codeine #3 -1T PO Q4H PRN

PE: Temp 102.6, Pulse 114, RR 18, BP 79/50,

Laboratory Findings: WBC 20.6, Hg 8.5, Na 131, K 2.6, Cl 2.6, CO2 24, BUN 17, Scr 1.5, Glucose 217, Ca 6.5,

Lactate 5.2, AST/ALT 61/91, MAP 59.67, PH 7.19, HCO3 17

Urinalysis: Protein 150, Blood Urine- Large, Leak Ester- Moderate, Nitrites (+), WBC 10-25, Bacteria-manyMicrobiology Blood Culture: Gram (-) Rods in aerobic Bottle. Urine Culture: Greater than 100,000 CFU/ML Pseudomonas Less than 10,000 CFU/ML of other organismDiagnosis: Septic Shock and Pyelonephritis secondary to Stent placement

Problem List Septic Shock

Objective▪ Heart Rate >90bmp▪ RR >22bpm▪ WBC >12,000▪ Severe HOTN▪ Elevated Lactate▪ Gram (-) rods on blood

culture

Pyelonephritis Subjective▪ Flank abdominal pain▪ Vomiting/headache/anxiety

Objective▪ Urinary Stent▪ Moderate Esterase▪ Pyuria▪ WBC 10-50K▪ Urine Culture: Pseudomonas

and other organism Metabolic Acidosis

Objective▪ pH less than 7.35 ▪ HCO3 less than 22 mEq/L

Medication Critique

Septic Shock The patient is receiving

the appropriate fluid therapy

Antibiotics▪ Gentamicin- Good Choice▪ Primaxin and Merrem-

Therapy Duplication▪ Flagyl- No indication

Vasopressors▪ Norepinephrine-DOC

Supportive Care▪ Glucose Control▪ Regular Insulin- Good Choice

▪ Stress Ulcer Prophylaxis▪ Protonix- Good Choice

Pyelonephritis Gentamicin- Good

Choice Primaxin and Merrem-

Not the DOC; therapy duplication

Metabolic Acidosis Sodium Bicarbonate

7.5%- Good Choice

Recommendations

Septic Shock Continue IV Normal

Saline Antibiotics▪ Tobramycin IV 500mg Q36H▪ Pseudomonal Coverage ▪ Maximizes concentration-

dependent killing activity

▪ Ceftazadime 1 gram IV q12h▪ Excellent Gram (-) infection

plus Pseudomonal Coverage

Vasopressors▪ Norepinephrine

1-4mcg/kg/min IV▪ Increase by 1-4 mcg/kg/min

titration to the desired effect

Supportive Care▪ Head of the bed elevation

30-45 degree angle▪ Analgesia▪ Fentanyl 200 mcg/hr IV

▪ Glucose Control▪ Regular Insulin- Good Choice

▪ Stress Ulcer Prophylaxis▪ Protonix 40 mg IVPB q6h-

Good Choice

▪ Agitation▪ Precedex- 0.4mcg/kg/hr via

IV

▪ DVT Prophylaxis▪ Lovenox 40 mg SQ QD plus

Compression Stockings High Risk Patient

RecommendationsPyelonephritis

Antibiotics▪ Tobramycin IV 500mg Q36H▪ Pseudomonal Coverage ▪ Maximizes concentration-dependent killing activity

▪ Ceftazadime 1 gram IV q12h▪ Excellent Gram (-) infection plus Pseudomonal Coverage

Metabolic Acidosis Sodium Bicarbonate 7.5%- Good Choice

Monitoring Parameters

Efficacy Serum Lactate- Goal less than 2.2mmol/L Central Venous Pressure-8-12 mmHg Mean Arterial Pressure- >65 mmHg Maintain urine output ≥0.5 mL/kg/hr a ScvO2 ≥70% Tobramycin▪ Trough at 6-14 hours after the first dose

CBC, WBC, LFT’s, symptoms of bleeding- everyday

Urinalysis and Blood Culture

Monitoring Parameters

Toxicity Aminoglycoside▪ Nephrotoxicty▪ Ototoxicity▪ Neuromuscular Blockade▪ HOTN

Ceftazadime▪ Anaphylaxis Reaction

Norepinephrine▪ Chest Pain▪ Palpitations▪ Extravasations

Toxicity Fentanyl▪ Respiratory Depression

Precedex▪ Hypotension▪ Bradycardia

Regular Insulin▪ Hypoglycemia

Lovenox▪ Bleeding▪ Decrease Hemoglobin level

Protonix▪ Diarrhea▪ Melena

Thank You!

References

Clinical Pharmacology-Gold Standard ( database online)2010.

MICROMEDEX® Healthcare Series: Micromedex, Greenwood Village, Colorado

DiPiro JT, Talbert RL, Hayes PE, Yee GC, Matzke GR, Posey Lm. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, N.Y.: Appleton & Lange Inc.2008. Chapter 123-Sepsis and Septic Shock