Nursing Pharmacology

Cardiac glycoside — increases cardiac contractility (positive inotrope), decreases heart rate (negative chronotrope). Therapeutic level: 0.5–2.0 ng/mL. Check apical pulse x1 min before giving; hold if HR <60 (adult), HR <100 (infant), or HR <70 (older child). Antidote: Digibind (digoxin immune fab).

Signs: N/V, anorexia, visual disturbances (yellow-green halos, blurred vision), bradycardia, dysrhythmias. Risk factors: hypokalemia (K+ <3.5), hypomagnesemia, hypercalcemia, renal impairment. Monitor potassium closely — low K+ increases dig toxicity.

End in '-olol.' Decrease HR, BP, and myocardial oxygen demand. Hold if HR <60 or SBP <90. Do NOT stop abruptly — taper to avoid rebound hypertension/tachycardia. Mask hypoglycemia symptoms in diabetics. Contraindicated in asthma (propranolol — nonselective), 2nd/3rd degree heart block. Monitor for fatigue, depression, erectile dysfunction.

End in '-pril.' Block conversion of angiotensin I to II — decrease BP, reduce preload/afterload. Side effects: persistent dry cough (switch to ARB if intolerable), hyperkalemia, angioedema (rare but emergent). Contraindicated in pregnancy (teratogenic). Monitor K+ and renal function (BUN/creatinine). First-dose hypotension — give at bedtime.

End in '-sartan.' Block angiotensin II receptors directly. Similar benefits to ACE inhibitors but do NOT cause dry cough (no bradykinin accumulation). Still contraindicated in pregnancy. Still monitor for hyperkalemia and renal function. Often used as alternative when ACE inhibitor cough is intolerable.

Dihydropyridines (amlodipine, nifedipine): end in '-dipine,' primarily vasodilate, reduce BP. Reflex tachycardia possible. Non-dihydropyridines (verapamil, diltiazem): reduce HR AND BP, used for rate control in afib. Both: monitor for hypotension, peripheral edema, constipation (especially verapamil). Avoid grapefruit juice (increases drug levels).

Vasodilator — primarily venous dilation, decreases preload. Sublingual: 1 tab q5min x3 doses max; call 911 if no relief after first dose (AHA guideline). Causes headache (expected), hypotension, reflex tachycardia. Remove patch at night (10-12 hr nitrate-free interval) to prevent tolerance. Store SL tabs in dark glass container; replace q6 months. Do NOT give with PDE5 inhibitors (sildenafil/Viagra) — severe hypotension.

Class III antiarrhythmic — used for life-threatening ventricular arrhythmias and afib. Toxicities affect multiple organs: pulmonary fibrosis (baseline and annual CXR + PFTs), thyroid dysfunction (hyper or hypo — contains iodine), hepatotoxicity (monitor LFTs), corneal microdeposits (eye exams), photosensitivity (sunscreen + protective clothing). Very long half-life (40-55 days). IV: monitor for hypotension, use inline filter.

First-line for SVT (supraventricular tachycardia). Give rapid IV push (6 mg, then 12 mg if needed) followed by rapid NS flush — use port closest to heart. Causes brief asystole (3-6 sec) — warn patient they may feel chest tightness/flushing. Ultra-short half-life (<10 sec). Have crash cart at bedside. Contraindicated in 2nd/3rd degree heart block.

IV or SubQ anticoagulant. Monitor aPTT — therapeutic range: 1.5–2.5x control (typically 46–70 sec). IV requires continuous infusion pump. Never give IM. Antidote: protamine sulfate (1 mg per 100 units heparin). Risk of HIT (heparin-induced thrombocytopenia) — monitor platelet count. No need to adjust for renal impairment.

Low-molecular-weight heparin (LMWH). SubQ only — administer in abdomen, do NOT aspirate or rub. Generally does not require routine lab monitoring. If monitored: anti-Xa level (0.5–1.0 IU/mL). Partial antidote: protamine sulfate (60% reversal). Adjust dose in renal impairment (CrCl <30: reduce dose). Longer half-life than UFH — given q12h or daily.

Oral anticoagulant — inhibits vitamin K-dependent clotting factors (II, VII, IX, X). Monitor PT/INR — therapeutic INR: 2.0–3.0 (mechanical valve: 2.5–3.5). Takes 3-5 days for full effect (overlap with heparin). Antidote: vitamin K (phytonadione) for non-urgent; fresh frozen plasma or PCC for bleeding. Highly interacting: consistent vitamin K intake, avoid cranberry, many drug interactions. Teratogenic — contraindicated in pregnancy.

Direct oral anticoagulants. Rivaroxaban (Xarelto) and apixaban (Eliquis): factor Xa inhibitors. Dabigatran (Pradaxa): direct thrombin inhibitor. Advantages: no routine INR monitoring, fewer food interactions, predictable pharmacokinetics. Reversal: dabigatran → idarucizumab (Praxbind); rivaroxaban/apixaban → andexanet alfa (Andexxa). Renal dose adjustment needed, especially dabigatran. Take rivaroxaban with food.

Beta-lactam antibiotics — inhibit cell wall synthesis. Ask about allergy before giving (cross-reactivity with cephalosporins ~1-2%). Amoxicillin: most common outpatient abx. Take on empty or full stomach. Watch for rash — maculopapular rash with EBV (mono) is NOT true allergy. Anaphylaxis risk: have epinephrine available. Complete full course. Can decrease oral contraceptive effectiveness.

Beta-lactams — generations 1-5. 1st gen (cefazolin): gram+ skin/surgical prophylaxis. 2nd gen (cefuroxime): broader. 3rd gen (ceftriaxone): meningitis, gonorrhea. 4th gen (cefepime): pseudomonas. 5th gen (ceftaroline): MRSA. Cross-allergy with PCN: ~1-2% (low but ask). Ceftriaxone: do NOT mix with calcium-containing solutions in neonates (fatal precipitate). Disulfiram-like reaction with alcohol (some cephalosporins).

End in '-floxacin.' FDA black box warnings: tendon rupture/tendinitis (especially Achilles — risk increased with corticosteroids and age >60), peripheral neuropathy, CNS effects (seizures, confusion), aortic aneurysm/dissection. Avoid in children <18 (cartilage damage). Separate from antacids/calcium/iron by 2 hours. Increases QT interval. Photosensitivity. Reserve for serious infections without alternatives.

End in '-mycin' (amino type). Bactericidal — gram-negative coverage. Two major toxicities: ototoxicity (hearing loss, tinnitus, vertigo — irreversible) and nephrotoxicity (monitor BUN/creatinine). Monitor peak and trough levels: gentamicin trough <2 mcg/mL, peak 5-10 mcg/mL (conventional dosing). Draw trough 30 min before dose, peak 30 min after infusion. Monitor I&O. Avoid concurrent nephrotoxic/ototoxic drugs.

Glycopeptide — used for MRSA, C. diff (oral only for C. diff). Updated 2020 guidelines recommend AUC/MIC-guided dosing (AUC 400-600) over traditional trough monitoring for serious MRSA infections. Traditional trough: 15–20 mcg/mL (drawn 30 min before 4th dose). Infuse over at least 60 min — rapid infusion causes Red Man Syndrome (flushing, hypotension — histamine release, not true allergy; slow rate and premedicate with diphenhydramine). Nephrotoxic and ototoxic. Monitor BUN/creatinine and hearing.

Opioid agonist — first-line for severe pain (MI, cancer). Adverse effects: respiratory depression (most dangerous — hold if RR <12), constipation (always order bowel regimen), sedation, urinary retention, hypotension, N/V, pruritus. Causes histamine release — can cause bronchospasm (avoid in asthma; use fentanyl or hydromorphone instead). Antidote: naloxone (Narcan). Assess pain using appropriate scale before and after administration.

Morphine 10 mg IV = morphine 30 mg PO = hydromorphone 1.5 mg IV = fentanyl 100 mcg IV. When converting between opioids, reduce dose by 25-50% for incomplete cross-tolerance. Fentanyl patch: 25 mcg/hr ≈ 60-90 mg oral morphine/day. Onset: fentanyl patch 12-24 hrs (not for acute pain). Always assess respiratory status with dose changes.

Inhibit COX-1 and COX-2 — anti-inflammatory, analgesic, antipyretic. Risks: GI bleeding/ulcers (take with food, consider PPI), renal impairment (monitor BUN/Cr, maintain hydration), increased bleeding risk (inhibit platelet aggregation), cardiovascular events (especially with prolonged use). Ketorolac: max 5 days total. Contraindicated in 3rd trimester pregnancy (premature ductus arteriosus closure). Avoid in renal failure, active GI bleed. Ceiling effect for pain relief.

Max dose: 4 g/day in healthy adults (2 g/day in liver disease or heavy alcohol use). Leading cause of acute liver failure. Toxicity signs: N/V in first 24 hrs → RUQ pain, elevated LFTs, jaundice at 24-72 hrs → hepatic failure at 72-96 hrs. Antidote: N-acetylcysteine (NAC) — most effective within 8 hours of ingestion. Monitor hepatic panel. Watch for hidden acetaminophen in combination products (Percocet, Vicodin, NyQuil).

Opioid antagonist — reverses respiratory depression, sedation, and analgesia. IV/IM/SubQ/intranasal. Onset: IV 1-2 min, IM 2-5 min. Duration: 30-90 min (shorter than most opioids — monitor for re-sedation and repeat dosing). Titrate to respiratory rate, not consciousness (to avoid acute withdrawal and severe pain). May precipitate acute withdrawal: agitation, tachycardia, N/V, diaphoresis. Intranasal: 4 mg in one nostril (community use).

First-line for depression and anxiety. Therapeutic effect takes 4-6 weeks. Side effects: sexual dysfunction, weight gain, GI upset, insomnia or drowsiness, headache. Serotonin syndrome risk if combined with MAOIs, tramadol, triptans (symptoms: hyperthermia, agitation, clonus, diaphoresis — treat with cyproheptadine). Black box warning: increased suicidality in children/adolescents/young adults (age <25) — monitor closely first 1-2 months. Do NOT stop abruptly — taper.

End in '-pam' or '-lam.' Enhance GABA — anxiolytic, sedative, anticonvulsant, muscle relaxant. Antidote: flumazenil (use cautiously — may precipitate seizures in chronic benzo users). CNS depression — do NOT combine with opioids or alcohol (respiratory depression risk). Lorazepam preferred in liver disease (no active metabolites — 'LOT' = Lorazepam, Oxazepam, Temazepam). Taper slowly — withdrawal can be fatal (seizures). Fall risk in elderly. Short-term use preferred.

Mood stabilizer for bipolar disorder. Narrow therapeutic index: 0.6–1.2 mEq/L. Draw trough level 12 hours after last dose. Toxicity signs: >1.5 mEq/L — N/V, diarrhea, coarse tremor, drowsiness; >2.0: ataxia, confusion, seizures; >2.5: life-threatening. Maintain adequate sodium and fluid intake (dehydration and low sodium increase lithium levels). Avoid NSAIDs, ACE inhibitors, thiazide diuretics (increase lithium levels). Monitor renal function, thyroid (causes hypothyroidism), pregnancy category D.

Typical/1st gen (haloperidol, chlorpromazine): block dopamine D2. High risk of EPS (dystonia → treat with benztropine/diphenhydramine, akathisia, parkinsonism, tardive dyskinesia — may be irreversible). Neuroleptic malignant syndrome (NMS): fever >104°F, muscle rigidity, altered LOC, elevated CK — stop drug, dantrolene, cooling. Atypical/2nd gen (risperidone, olanzapine, quetiapine, clozapine): fewer EPS but metabolic syndrome (weight gain, hyperglycemia, dyslipidemia). Clozapine: requires ANC monitoring (agranulocytosis risk).

Lispro (Humalog), Aspart (NovoLog), Glulisine (Apidra). Onset: 10-15 min. Peak: 1-2 hrs. Duration: 3-5 hrs. Give within 15 min of eating. Clear solution. Only Regular insulin is used IV; rapid-acting insulins (lispro, aspart) are SubQ only. Used for mealtime coverage and correction doses. Highest hypoglycemia risk at peak time — ensure patient eats after injection.

Onset: 30 min. Peak: 2-4 hrs. Duration: 6-8 hrs. Give 30 min before meals. Clear solution. ONLY insulin given IV (for DKA, hyperkalemia). Used in sliding scales. Can be mixed with NPH (draw Regular first — 'clear before cloudy'). Monitor glucose and potassium (insulin shifts K+ intracellularly).

NPH (Humulin N, Novolin N). Onset: 1-2 hrs. Peak: 4-8 hrs. Duration: 12-16 hrs. Cloudy solution — gently roll, do not shake. Can be mixed with Regular (draw Regular first). Given 1-2x daily. Unpredictable peak makes hypoglycemia risk variable. Never give IV. Often combined with rapid-acting for better coverage.

Glargine (Lantus, Basaglar): Onset 1-2 hrs, no peak (steady state), duration ~24 hrs. Detemir (Levemir): Onset 1-2 hrs, mild peak 6-8 hrs, duration 12-24 hrs. Both are clear solutions. Do NOT mix with other insulins. Given once or twice daily. Provide basal coverage. Glargine: acidic pH — do not mix (precipitates). Degludec (Tresiba): ultra-long-acting, duration >42 hrs.

Biguanide — first-line for Type 2 DM. Decreases hepatic glucose production, increases insulin sensitivity. Does NOT cause hypoglycemia (when used alone). GI side effects common (start low, take with food). Serious risk: lactic acidosis — contraindicated if eGFR <30, active liver disease, heavy alcohol use. Hold at time of contrast and 48 hrs AFTER (current ACR guidelines). Monitor B12 (can cause deficiency with long-term use). No weight gain (may promote modest weight loss).

Synthetic T4 — hypothyroidism replacement. Take on empty stomach, 30-60 min before breakfast, with water only. Separate from calcium, iron, antacids by 4 hours (decrease absorption). Monitor TSH q6-8 weeks after dose changes. Goal TSH: 0.5-4.0 mIU/L. Narrow therapeutic index — maintain same brand. Toxicity signs = hyperthyroidism: tachycardia, weight loss, heat intolerance, tremor, insomnia. Requires lifelong therapy.

Short-acting beta-2 agonist (SABA) — rescue inhaler for acute bronchospasm (asthma, COPD). Onset: 5-15 min. Duration: 4-6 hrs. Side effects: tachycardia, tremor, hypokalemia, nervousness. If using >2x/week for rescue, asthma is not well-controlled — step up therapy. Rinse mouth after use if using MDI. For nebulizer: 2.5 mg/3 mL. Using more than 1 canister/month indicates poor control.

Anticholinergic bronchodilator — blocks acetylcholine in bronchial smooth muscle. Used for COPD maintenance (less effective in asthma). Onset: 15-30 min. Duration: 4-6 hrs. Side effects: dry mouth, urinary retention, constipation, blurred vision. Use with caution in patients with soy or peanut allergy (MDI formulation contains soy lecithin; nebulizer solution does not). Often combined with albuterol (Combivent/DuoNeb). Not a rescue inhaler — slower onset than albuterol.

Anti-inflammatory — cornerstone of persistent asthma maintenance. NOT for acute attacks. Rinse mouth and spit after each use to prevent oral candidiasis (thrush). Use spacer with MDI for better delivery. Side effects: hoarseness, oral thrush, pharyngitis. Systemic steroids (prednisone): taper if used >2 weeks — adrenal suppression. Monitor glucose, bone density, and growth in children with long-term use.

End in '-prazole.' Irreversibly block H+/K+ ATPase (proton pump) — most potent acid suppression. Take 30-60 min before first meal. Used for GERD, peptic ulcers, Zollinger-Ellison. Long-term risks (>1 year): C. diff infection, bone fractures (decreased calcium absorption), hypomagnesemia, vitamin B12 deficiency, kidney disease. FDA recommends shortest duration at lowest dose. Do not stop abruptly (rebound acid hypersecretion). IV pantoprazole for active GI bleed.

End in '-tidine.' Block histamine H2 receptors on parietal cells — reduce acid secretion (less potent than PPIs). Famotidine (Pepcid): most commonly used (ranitidine/Zantac recalled for NDMA carcinogen). Faster onset than PPIs but shorter duration. Can be given IV. Fewer long-term risks than PPIs. Used for mild GERD, stress ulcer prophylaxis in ICU. Can cause headache, dizziness, constipation.

5-HT3 receptor antagonist — blocks serotonin in CTZ and vagal nerve. First-line antiemetic for chemotherapy, postoperative, and general N/V. Given IV, PO, or ODT (sublingual dissolving tab). Key side effect: QT prolongation — obtain baseline ECG in at-risk patients, avoid in patients with long QT syndrome. Other side effects: headache, constipation. Max IV dose: 16 mg (FDA). Serotonin syndrome risk with SSRIs (rare).

Dopamine antagonist — prokinetic (increases GI motility) and antiemetic. Used for gastroparesis, GERD, N/V. Black box warning: tardive dyskinesia with long-term use (>12 weeks) — may be irreversible. Can cause EPS (especially in young patients). Contraindicated in bowel obstruction, pheochromocytoma, seizure disorders. Give 30 min before meals. Monitor for involuntary movements.

Medications that carry heightened risk of significant harm if used in error. ISMP high-alert list includes: insulin, opioids, anticoagulants (heparin, warfarin), potassium chloride (IV), chemotherapy, neuromuscular blocking agents, concentrated electrolytes. Safety measures: independent double-check, barcode scanning, tall-man lettering, limit access to concentrated forms, standardized concentrations, smart pump drug libraries. Never abbreviate 'U' for units — write 'units.'

Never crush: enteric-coated (EC) tablets (destroy protective coating — GI irritation or inactivation), extended/sustained-release formulations (dose dumping — potential overdose), sublingual tabs (designed for buccal absorption), teratogenic drugs (exposure risk to handler). Examples: metoprolol succinate ER, oxycodone ER, omeprazole capsules (can open and sprinkle but not crush beads), potassium chloride ER. Always check before crushing; request liquid alternative if available.

Dopamine: dose-dependent effects — low dose (1-5 mcg/kg/min): renal vasodilation; moderate (5-10): increases cardiac output (beta-1); high (10-20): vasoconstriction (alpha). Note: Evidence does not support renal-dose dopamine for renal protection. Dobutamine: primarily beta-1 agonist — increases contractility without significant vasoconstriction. Used for acute heart failure. Both: continuous infusion only, central line preferred, monitor ECG continuously. Dobutamine can cause hypotension (vasodilation at higher doses).

Anticholinergic — increases heart rate by blocking vagal tone. First-line for symptomatic bradycardia (0.5 mg IV q3-5 min, max 3 mg). Also used for organophosphate poisoning (high doses). Side effects: tachycardia, dry mouth, urinary retention, blurred vision, decreased GI motility. Contraindicated in narrow-angle glaucoma. In ACLS: used before transcutaneous pacing for unstable bradycardia.

Thrombolytic — converts plasminogen to plasmin, dissolves clots. Indications: acute ischemic stroke (within 4.5 hrs of onset), STEMI (if PCI not available), massive PE. Stroke dose: 0.9 mg/kg (max 90 mg) — 10% bolus, rest over 60 min. Contraindications: active bleeding, recent surgery (14 days), uncontrolled HTN (>185/110), INR >1.7, platelet <100,000. Nursing: neuro checks q15 min, no invasive procedures, monitor for bleeding, BP management, no anticoagulants for 24 hrs post.

Monoamine oxidase inhibitors — rarely used, last-line antidepressants. CRITICAL: avoid tyramine-rich foods — aged cheese, cured meats, red wine, soy sauce, sauerkraut, tap/draft beer. Tyramine + MAOI = hypertensive crisis (severe headache, stiff neck, diaphoresis, BP >180/120 — can be fatal). Treat with phentolamine (alpha-blocker). Also avoid SSRIs, meperidine, pseudoephedrine (serotonin syndrome, hypertensive crisis). Washout period: 14 days before/after other antidepressants.

Anti-inflammatory, immunosuppressive. Side effects (mnemonic: CUSHINGOID): Cataracts, Ulcers, Skin thinning/Striae, Hyperglycemia/HTN, Infections, Necrosis (avascular), Growth suppression, Osteoporosis, Immunosuppression, Diabetes/weight gain (buffalo hump, moon face). Take in AM (mimics cortisol rhythm). Take with food. Never stop abruptly if >2 weeks (adrenal crisis). Monitor glucose, K+, weight. Increase risk of infection — avoid live vaccines. Taper gradually.

Regular insulin given based on blood glucose readings (typically q4-6h or AC/HS). Always verify: correct insulin type, correct dose per protocol, blood glucose value, and patient identity. Check glucose before meals and at bedtime. Hold and notify provider if glucose <70 mg/dL. Treat hypoglycemia with Rule of 15: 15g fast-acting carbs, recheck in 15 min. Document glucose and insulin given. Assess for signs of hypo (shakiness, diaphoresis, confusion) and hyperglycemia (polyuria, polydipsia, Kussmaul respirations in DKA).

Commonly confused pairs: hydrOXYzine (antihistamine) vs hydrALAZINE (antihypertensive), predniSONE vs prednisoLONE, metFORMIN vs metroNIDAZOLE, DOPamine vs DOBUTamine, ceREBYX (fosphenytoin) vs ceLEBREX (celecoxib), vinCRIStine (IV only) vs vinBLAStine. Prevention: use tall-man lettering, read labels carefully, barcode scanning, separate storage. VinCRIStine is FATAL if given intrathecally (IV only — must be in minibag per ISMP).

NEVER give IV push — fatal cardiac arrest. Always dilute: max concentration 40 mEq/L in peripheral line (up to 80 mEq/L central line with cardiac monitoring). Max rate: 10 mEq/hr peripheral (20 mEq/hr central with monitoring). Burns at infusion site — assess IV frequently. Must have adequate urine output (>0.5 mL/kg/hr) — kidneys excrete K+. Monitor ECG for tall peaked T waves (hyperkalemia). Verify serum K+ level before and after infusion.

Anticonvulsant — narrow therapeutic index: 10–20 mcg/mL. IV: give slowly (max 50 mg/min) — only with NS (precipitates in dextrose). Monitor ECG and BP during IV infusion (risk of hypotension, bradycardia, cardiac arrest). Side effects: gingival hyperplasia (oral hygiene), hirsutism, nystagmus at toxic levels, ataxia, Stevens-Johnson syndrome. Many drug interactions (CYP450 inducer). Monitor free phenytoin if low albumin. Highly teratogenic.

Indications: preeclampsia/eclampsia (seizure prophylaxis), torsades de pointes, severe hypomagnesemia. Therapeutic level: 4–7 mEq/L for preeclampsia. Toxicity progression: decreased DTRs (first sign — check patellar reflex) → respiratory depression → cardiac arrest. Monitor: DTRs, RR (hold if <12), urine output (>30 mL/hr — renally excreted), LOC. Antidote: calcium gluconate (1 g IV slow push). Keep at bedside. Continuous fetal monitoring in OB patients.

1. Right patient (2 identifiers) 2. Right drug 3. Right dose 4. Right route 5. Right time 6. Right documentation 7. Right reason (indication) 8. Right response (evaluate effectiveness) 9. Right to refuse 10. Right education (teach patient about the medication). Always check allergies. Three safety checks: when pulling from drawer/Pyxis, when preparing, when at bedside before giving. If unsure, DO NOT GIVE — verify with pharmacy.

Catecholamine — alpha and beta agonist. Anaphylaxis: 0.3-0.5 mg IM in anterolateral thigh (1:1,000 concentration = 1 mg/mL); pediatric: 0.01 mg/kg (max 0.3 mg). May repeat q5-15 min. EpiPen: adult 0.3 mg, junior 0.15 mg. Cardiac arrest (ACLS): 1 mg IV/IO q3-5 min (1:10,000 concentration). Also used for severe asthma, croup (racemic epi nebulizer). Side effects: tachycardia, hypertension, tremor, anxiety. Monitor ECG, BP. Never give 1:1,000 IV (use 1:10,000 for IV).

Osmotic diuretic — increases serum osmolality, draws fluid from tissues (brain, eyes). Used for: increased intracranial pressure (ICP), acute glaucoma, cerebral edema. IV administration only — use filter needle (may crystallize). Monitor serum osmolality (hold if >320 mOsm/kg). Monitor I&O strictly (expect large urine output). Monitor electrolytes (hyponatremia, hypokalemia). Assess neuro status. Contraindicated in anuria, severe dehydration, active intracranial bleeding.

Life-threatening condition from excess serotonergic activity. Triad: altered mental status (agitation, confusion), autonomic instability (hyperthermia, diaphoresis, tachycardia, BP changes), neuromuscular excitability (clonus, hyperreflexia, rigidity, tremor). Causes: combining SSRIs + MAOIs, SSRIs + tramadol, SSRIs + triptans, SSRIs + linezolid, meperidine + MAOIs. Treatment: stop offending agents, cyproheptadine (serotonin antagonist), benzodiazepines for agitation, cooling measures. Distinct from NMS (which involves dopamine blockade and lead-pipe rigidity).

Used for acute heart failure, unstable angina, hypertensive emergency. Must use glass bottles and non-PVC tubing (drug absorbs into PVC plastic, reducing delivered dose). Titrate to BP and chest pain relief. Monitor BP every 5-15 min during titration. Headache is expected (give acetaminophen). Maintain SBP >90. Use dedicated IV line if possible. Tolerance develops with continuous use. Wean gradually — do not stop abruptly.

Called 'ampho-terrible' due to severe side effects. Major toxicity: nephrotoxicity (monitor BUN/Cr, I&O — prehydrate with NS). Infusion reactions: fever, chills, rigors, N/V (premedicate with acetaminophen, diphenhydramine, meperidine for rigors). Hypokalemia, hypomagnesemia (replace electrolytes). Anemia with prolonged use. Liposomal formulation (AmBisome) has fewer side effects. Test dose may be given first. Infuse slowly over 2-6 hours.