Constipation

• You can add constipation protocol to have a nursing driven list of medications; but you need to check they are following it

• If you need something one time dose, you can use:

  • Milk of mag (oral)

  • Milk of molasses (enema, but the molasses looks like feces, so it’s difficult)

  • Senokot

  • Miralax

  • Tap water enema, fleet enema

• Simethicone - gas pains

Diarrhea

• Make sure it’s not infectious diarrhea (e.g. C. Diff)

• Can consider a short course (<5-7 days) of rectal tube insertion as long as they have no rectal pathology (e.g. recent surgery, bleeding hemorrhoids, rectal varices)

• Imodium

• Bismuth sulfate (pepto-bismol)

Indigestion/Acid Reflux/Increased TF residual

• Tums (calcium carbonate) - immediate relief

• Famotidine (Pepcid), Ranitidine (Zantac) syrup or tab

• Metoclopramide (Reglan) - can give IV for incr tube feed residual

• Sucralfate (Carafate) tablet

Nausea/Vomiting

• IV/PO Zofran (monitor QTC)

• Reglan (monitor QTC)

• Phenergan: can cause somnolence

• Add aspiration precautions in the instance of actual vomiting

  • Other meds not used often: zyprexa (advanced cancer), ativan (chemo induced nausea)

Cough

• Dextromorphan-guaifenesin (Robitussin) - antitussive + expectorant

• Benzonatate (Tessalon) capsules - antitussive

• Mucinex - expectorant

Wheezing/SOB

• Duo-nebs (albuterol/ipratropium)

• Xopenex if issues with HR (must order as non-formulary)

Loss of Appetite

• Dronabinol (Marinol) capsule (specifically in AIDS), used more commonly

• Megestrol (Megace) -watch in patients with CHF/volume overload, increases VTE risk

Essential Hypertension

• Usually HTN is preceded by something (pain, anxiety) - make sure you treat any preceding factors prior to fixing HTN

• Restart home meds if able

• PRNs:

  • IV Hydralazine (5, 10 or 20) = not as effective

  • IV labetalol (10, 20 or 40) = more effective (if HR can tolerate)

  • IV Metoprolol (if HR can tolerate), very short acting

Mild Itching/Allergy

• Both H1/H2 blockers: Benadryl (25-50 PO), Pepcid

• Hydrocortisone cream

Pain

• Always assess mental status prior to giving analgesia, and always ask where their pain is

• “What do they take at home?”

  • PO: Tylenol for mild pain, Tramadol or Percocet for severe pain

  • IV: morphine

  • Chest pain: IV morphine for dilation of cardiac vessels, nitroglycerin in setting of ACS as long as BP can tolerate

  • Unable to take opioid: Ketorolac (Toradol)

  • Nerve pain (e.g. “shooting” pain): gabapentin

Headache

• Ask if they have a history of migraines

• “What do they take at home?”

• PO: Tylenol

• Migraines: Triptan drugs (i.e. sumatriptan)

• FIORICET: this is helpful for patients who are having a caffeine withdrawal headache but avoid at night

AGITATION/Delirium

• The best way to treat delirium is non-pharmacologically (see P/A/D podcast)

• Non-BZDs are ideal. Should only use drugs if you absolutely have to - HAVE to know QTC

  • Haldol IV

  • Seroquel PO (takes time - ICU delirium dosing is BID)

  • Zyprexa sublingual

  • IM drugs in cases of violence/threat, hurts to give: Geodon, Ativan, Haldol

• 3rd line treatment: More and more since 2022 onward you will see Precedex Drip for agitation - it’s not expensive, it’s on formulary, it’s titratable; but it keeps you in the ICU so you should avoid this in any patient that you have plans on transferring out

Increased Secretions on Vent

• Two issues come into play: inability to cough up secretions (physical component) and secretions themselves

  • Hypertonic saline nebs - Thin the secretions

  • Mucomyst nebs - you will hear this but there are no studies showing this works

• Can use chest physiotherapy to help break up secretions

• Mobilize, mobilize, mobilize

Insomnia

• Melatonin (3mg)

• Restoril

• Benadryl (avoid in elderly - they can get crazy on this)

• Trazodone - also an antidepressant

• Consider Ambien if they are on it at home but in general try to avoid in critically ill

Fever

• Tylenol - PO or rectal

• If severe enough: think malignant hyperthermia, can place icycath to cool, ice packs

** please do not place ice bags on patient for fever unless the temp needs to be urgently decreased (malignant hyperthermia, serotonin syndrome, temp > 104F) - these hurt!