Class Serotonin antagonists DA antagonists Histamine antagonists ‘ACh antagonists DA/Histamine/ACh antagonist Neurokinin-1 receptor antagonists Centrally acting Medication Ondansetron (otran) Granisetron (Kytril, Sancuso) ‘Metoclopramide (Regian) Olanzapine (zyprexa) Prochlorperazine (compazine) Haloperidol (Haldol) Diphenhydramine (Benadryl) Scopolamine Promethazine (Phenergan) ‘Aprepitant (Emend) Fosaprepitant (Iverend) Dexamethasone THC, dronabinol Lorazepam (Ativan) ENE Route PO, IVP, IM, sublingual PO, Iv, transdermal PO, IVP, IM PO, IM, sublingual PO, IVP, PR PO, IM PO, IVPB, ve PO, IVP, IM, transdermal PO, PR, IVP, IM PO. v PO, IVP, IM PO PO, IVP, IM Common Side Effects or Prolongation v Headache, constipation, drowsiness, diarthea v Drowsiness, EPS, do not use if increased GI motility “i PS, hyperglycemia ~ EPS, NMS EPS, constipation, dry mouth, blurred vision, somnolence v Dizziness, drowsiness, paradoxical excitation ey Bradycardia, flushing, thirst xerostomia, urinary) retention EPS, NMS, drowsiness, sedation, leukopenia, r thrombocytopenia Hiccups, bradycardia, neutropenia ‘Angloedema, bradycardia, neutropenia Leukocytosis, mood changes, adrenal suppression, hyperglycemia Hyperemesis, tachycardia, nystagmus, ataxia Respiratory depressionele Tao erel to 3 Class (Mechanism) Medication Side Effects Nausea, bloating, Polyethylene glycol cramping Osmotic agents (draws Lactulose Abdominal bloating, water into bowel, thereby Sorbitol flatulence loosening stool and ae Glycerin Rectal irritation promoting evacuation) Stimulant laxatives Bulk-forming laxatives (fiber absorbs excess water and stimulates elimination) Magnesium citrate Magnesium sulfate PO Watery stools and urgency Bisacodyl Rectal irritation Senna Melanosis coli Impaction above Psyllium strictures, fluid overload, gas, and bloating Rectal distension Tap water enema Discomfort during procedure(Ata eer a en ce Route Frequently Used os as Effect Po Rane Relative/Absolute Contraindications 315 Bradycardia, heart block, ADHF, Class B-blockers | ¥ Metoprolol, Labetalol acca cee ° | Captopril (PO), ACEI/ARBs viv Enalaprilat (IV), AKI, hyperkalemia, angioedema eo | Lisinopril, Benazepril a2 agonists | V | Vv Clonidine Severe bradycardia ° Nitrates! V_ | ¥___ Isosorbide dinitrate Severe AS, patients on PDE inhibitors | Nifedipine ER, | a Bradycardia, heart block (for non- ces? viv Diltiazem, i ist ° | Amlodipine dihydropyridines), HFrEF ae viv Chlorthalidone, AKI, hypovolemia, difficulty with v | Spironolactone transferring to urinate Vasodilators Vv Hydralazine Can develop severe reflex t Non-selective a | , tachycardia due to the unpredictable Blockers | v Phentolamine drop in SBP v Partial D1 | ianiie |v Fenoldopam Glaucoma or 1, Transdermal formulation is available 2. Amlodipine takes approximately 30 hours to become effectiveSEs ‘Acetaminophen (24 hours: <3-4g in healthy adults, <3g in CKO, <2g in liver disease or cirrhosis) [NSAIDs (avoid if CKD or >2 of the following risk factors: h/o GI ulcer, age >60, on steroids, on ASA/AC) Moderate Pain (4-7) Hydrocodone, Tylenol #3, Tylenol #4, tramadol, IV Toradol (avoid if CKO) Mild Pain (1-3) WV,SC, PO dose : ones | (MSS, | POM pawv | net | peak | Duatin | tn Sani Vrscmamtone | asme | 75e5 | aa | Wem | aS" | asm | oan dese ee Ge gE a Ye ae panera cotati 200mg at morphine in liver Tramadol _ 120mg _ ah 2h 4-6h 6-8h ‘fivold MAO! used In last 144 ‘Can | seizure threshold Different tables will reference different values ~ choose one and stick with it \When rotating chronic opioid, consider reducing equivalent dose by 25-50% to account for incomplete cross tolerance ©. Transdermal fentanyl patch is only used for opioid-tolerant patients and requires pain management/paliative care to titrate. If patients with hepatic and renal failure, fentanyl is preferred. Time to steady-state for patch is upto 36h. If patch is removed, half-life is 17h 4. If patients with renal failure, consider hydromorphone, oxycodone, fentanyl, or methadone(© Update family/DPOA on status of patient O Fill out/update POLST form (if indicated) © Post-hospitalization living situation G Insurance for meds (prior authorization) and nursing homes 3 Post-discharge transport D Equipment at home for safety/function © Outpatient referrals and appointments. © Consider need for prescriptions (new medications, refills) G Discharge medication education © Handoff communication to accepting provider (PMD, SNFist, etc) Indications for NPO 1 Upcoming procedure 1G PET scan (also avoid dextrose-containing fluids ~ review all IV meds) FEN/GI © Concern for aspiration of all PO intake (including medications) © Avoid caffeine prior to regadenoson stress testing ‘Maintenance IV fluids (always put end-time/total amount and review every 24 hours) Oi SCDs 0 Enoxaparin subQ if CrCl >30 (hold 24 hours before Dvt most procedures) prophylaxis Heparin subQ if CrCl <30 (hold 6 hours before most procedures) Contra-indications: active bleeding, low platelets Indications History of GERD (and on meds as outpatient) GI D On mechanical ventilator for >48 hours prophylaxis [2 Coagulopathy (INR >1.5, plt <50) © High-dose/chronic steroid or NSAID use © Recent Gi bleed Full, DNR/DNI, DNR/okay to intubate, no compressions/DNI* Code “At the VA, patients cannot legally have mixed code status (patients must be Full Code or DNR/DNI)