Torsemide torasemide Miscellaneous cardiac drugs

Amrinone Dobutamine Dopamine Milrinone Nitroglycerine Nitroprusside Barbiturates Pentobarbital (pentobarbitone) Phenobarbital (phenobarbitone) Secobarbital (quinalbarbitone) Benzodiazepinesm Chlordiazepoxide Diazepam Lorazepam

15-75 pg/kg IV Many routes and methods 0

30 mg 50-100 mg 30-50 mg

Three times daily Twice daily Every 24 h Twice daily

Min Min

<10 min Load

10 min

Three to four times daily Two to three times daily Three to four times daily

Every 24 h Every 24 h

Two to three times daily

100%

Every 8-12 h 100%

100%

Every 8-12 h 100%

Avoid 100% 100% 100%

100%

Every 12-16 h 100%

Midazolam

Individualized

100%

100%

S0%

Narcotics and narcotic antagonists

Alfentanil

Anesthetic induction

100%

100%

100%

Butorphanol

2.0 mg

Every 3-4 h

100%

7S%

S0%

Codeine

30-60 mg

Every 4-6 h

100%

7S%

S0%

Fentanyl

Anesthetic induction

100%

7S%

S0%

Meperidine (DemerolĀ®)

50-100 mg

Every 3-4 h

100%

7S%

S0%

Methadone

2.5-10 mg

Every 6-8 h

100%

100%

S0%-7S%

Morphine

20-25 mg

Every 4 h

100%

7S%

S0%

Naloxone

2.0 mg IV

100%

100%

100%

Sufentanil

Anesthetic induction

100%

100%

100%

Drug

First dose

First interval

GFR>5G

GFR 1G-5G

GFR<1G

Anticonvulsants

Carbamazepine

200 mg

Twice daily

100%

100%

100%

Phenytoin

1000 mg

Load

100%

100%

100%

Primidone

250-500 mg

Four times daily

Every 8 h

Every 8-12 h

Every 12-24 h

Sodium valproate

15-60 mg/kg

Every 24 h

100%

100%

100%

Corticosteroids

Betamethasone

0.5-9.0 mg

Daily

100%

100%

100%

Dexamethasone

0.75-9.0 mg

Daily

100%

100%

100%

Hydrocortisone

20-500 mg

Daily

100%

100%

100%

Methylprednisolone

4-48 mg

Daily

100%

100%

100%

Neuromuscular agents

Atracurium

0.4-0.5 mg/kg

Load

100%

100%

100%

Doxacurium

0.025-0.05 mg/kg

100%

S0%

S0%

Etomidate

0.2-0.6 mg/kg

100%

100%

100%

Fentanyl

0.0002-0.05 mg/kg

100%

100%

100%

Gallamine

0.5-1.5 mg/kg

7S%

Avoid

Avoid

Ketamine

1-4.5 mg/kg

100%

100%

100%

Metocurine

0.2-0.4 mg/kg

7S%

S0%

S0%

Neostigmine

15-375 mg

Daily

100%

S0%

2S%

Pancuronium

0.04-0.1 mg/kg

100%

S0%

Avoid

Pipecuronium

100 pg/kg

100%

S0%

2S%

Propofol

2-2.5 mg/kg

100%

100%

100%

Pyridostigmine

60-1500 mg

Daily

S0%

3S%

20%

Succinylcholine (suxamethonium)

0.3-1.1 mg/kg

Load

100%

100%

100%

Sufentanil

1-30 pg/kg

100%

100%

100%

Tubocurarine

0.1-0.2 mg/kg

7S%

S0%

Avoid

Vecuronium

0.08-0.1 mg/kg

Load

100%

100%

100%

GFR, glomerular filtration rate; ACE, angiotensin-converting enzyme; IV, intravenous. Performing therapeutic drug monitoring

GFR, glomerular filtration rate; ACE, angiotensin-converting enzyme; IV, intravenous. Performing therapeutic drug monitoring

Therapeutic drug monitoring is defined as applying clinical pharmacokinetics to achieve a desirable clinical response by measuring and interpreting plasma drug concentrations. Therapeutic drug monitoring is particularly important for drugs with a narrow therapeutic index, for drugs which are subject to considerable intra- and interpatient variability, for drugs which are used for chronic diseases such as seizures and arrhythmias, for evaluating the possibility of drug toxicity and suspicion of non-compliance, for evaluating possible drug-drug, drug-food, and drug-disease interactions, and for patients with unstable renal function. Therapeutic drug monitoring should be used with some caution in patients with renal dysfunction. Clinical response must be used as the endpoint of pharmacotherapy; simply achieving and maintaining a plasma concentration in the drug's therapeutic range is neither sufficient nor adequate ( Rudy.i.and..BrateL1994).

Drugs in this chapter are listed by generic name and therapeutic use. It should be emphasized that Table 1 is intended to provide a rough guideline to assist the clinician in drug therapy for patients with renal dysfunction (with some limitations). This recommendation should only be used as a starting point. Dosages may vary or a drug should be completely avoided according to a patient's other pathological factors.

Renal replacement therapy, particularly continuous arteriovenous hemofiltration and continuous venovenous hemofiltration, is gaining popularity in the management of renal failure in hemodynamically unstable patients in the intensive care setting. Drug replacement and extent of drug removal by these extracorporeal processes should be considered for designing appropriate and effective drug therapy for patients with acute renal failure. The specific properties of the drug that influence removal of active moiety are as follows:

1. molecular weight;

2. water solubility;

3. protein binding;

4. volume of distribution;

5. dialysis clearance compared with plasma clearance.

For example, as the molecular weight of the drug increases, removal during extracorporeal processes decreases. Once the molecular weight exceeds 500 Da, conventional dialysis is not very effective in drug removal. Lipophilic drugs and agents with a large volume of distribution should not be expected to dissolve in aqueous dialysate and be removed from the blood during dialysis. Drugs with a high degree of protein binding are not significantly removed by the extracorporeal process, with the exception of plasmapheresis, because of the formation of a large drug-protein complex. Therefore, to ensure efficacy and avoid toxicity, appropriate replacement should be considered during dialysis ( BenneiLeLal 1994).

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