Penn Pearls

Common Orders and PRNs

Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.

Pain

• First line: Tylenol (acetaminophen) 650-1000mg per dose, Motrin (ibuprofen) 200-800mg per dose, Aleve (naproxen) 250-500mg per dose
• Second line: Neurontin (gabapentin) 100-300mg initial dose, lidocaine patch 5%, Flexeril (cyclobenzaprine)
• Third line: Lyrica (pregabalin, controlled substance), tramadol (controlled substance), Tylenol #3 (acetaminophen-codeine, controlled substance)
• Fourth line: oxycodone, morphine PO or IV, Dilaudid (hydromorphone) PO or IV
• Conversions: Dilaudid (hydromorphone) PO:IV is 5:1, morphine PO:IV is 3:1

Headache

• First line: Tylenol (acetaminophen), Motrin (ibuprofen) or Aleve (naproxen), IV fluids, Excedrin (aspirin-acetaminophen-caffeine)
• Second line: Fioricet (butalbital-acetaminophen-caffeine), Toradol (IV ketorolac) with Reglan (metoclopramide), Imitrex (sumatriptan, careful in stroke and seizure patients)

Cough

• First line: Mucinex (guaifenesin), Robitussin (guaifenesin-dextromethorphan)
• Second line: guaifenesin-codeine

Nausea

• First line: Zofran (ondansetron), Compazine (prochlorperazine), Phenergan (promethazine, IV no longer available at UPHS)–careful of QTc
• Second line: Reglan (metoclopramide), Tigan (trimethobenzamide), scopolamine patch
• Third line: Ativan (lorazepam), Decadron (dexamethasone), nasogastric tube

Constipation

• First line: Senna, Colace (docusate), Miralax (polyethylene glycol), Dulcolax PO (bisacodyl)
• Second line: lactulose, magnesium citrate
• Third line: bisacodyl suppository, tap water enema, mineral oil enema, Fleet enema, manual disimpaction, Golytely (polyethylene glycol x 4 liters)

Heartburn

• Fast acting: Maalox (aluminum hydroxide-magnesium hydroxide, renal patients will accumulate aluminum and magnesium), Pepcid (famotidine on formulary)
• Slow acting: Prevacid (lansoprazole on formulary)

Diarrhea

• First line: Imodium (loperamide), Pepto-Bismol (bismuth subsalicylate)
• Second line: Lomotil (atropine-diphenoxylate, controlled substance)
• Third line: Creon/ZenPep (pancreatic enzymes), Sandostatin (octreotide)

Colonoscopy Preparation

• Option 1: clear liquid diet morning before scope, 4pm start Golytely (polyethylene glycol) 4 liters, midnight stool check and if not clear then order 2 more liters of Golytely then NPO other than bowel prep starting at midnight
• Option 2 (for those sensitive to volume overload or who cannot drink full prep): clear liquid diet morning before scope, Moviprep with 20mg PO Dulcolax (bisacodyl) and 238 grams (14 packets of 17 grams each) of Miralax (polyethylene glycol) dissolved in 64 ounces of liquid
• No red or purple liquids
• If cannot tolerate full prep, may need Dobhoff or nasogastric tube

Itching

• First line: Eucerin ointment, Sarna (camphor-menthol lotion), Atarax (hydroxyzine), Benadryl (diphenhydramine)
• Second line: hydrocortisone lotion, triamcinolone cream
• Third line: cholestyramine, ursodiol

Insomnia/Sleep

• First line: melatonin
• Second line: Benadryl (diphenhydramine)
• Third line: Restoril (temazepam)

Tranfusion: RBCs

• Hemoglobin goal usually > 7 or higher if actively bleeding or hemodynamically unstable
• Consider hemoglobin goal > 6 for some sickle cell patients
• Consider hemoglobin goal > 8 for active cardiac ischemia
• Usually 1 unit RBCs raises hemoglobin by about 1.0 g/dL

Transfusion: FFP

• FFP goal usually < 2 for procedures
• Remember FFP has an INR of 1.6 itself so it will not lower the INR beyond this point

Tranfusion: Platelets

• Platelet goal usually > 10 in most patients, > 50 if active bleed or most procedures, > 100 if brain bleed or CSF-related procedure (LP)
• Usually 1 unit of platelets raises platelet count by 10-25k/microliter

Transfusion: Cryoprecipitate

• Goal fibrinogen usually > 100
• Transfuse 10 units of cryoprecipitate at a time

Repletion: Potassium

• Goal is around 4.0 mEq/L but if no drop expected (ex: no diuresis) then above 3.5 mEq/L usually doesn’t need repletion
• For dialysis/severe CKD: consider repleting only halfway (if 3.2 then replete up to 3.6 instead of 4.0)
• Potassium chloride PO: 10mEq raises K by 0.1 mEq/L (max 60mEq at once)
• Potassium chloride IV: 10mEq raises K by 0.1 mEq/L (max 60mEq at once, central line formulation comes with less fluid than peripheral line formulation, every 10mEq IV takes 1 hour to infuse)

Repletion: Magnesium

• Goal is around 2.0 mg/dL but if no drop expected (ex: no diuresis) then 1.8 mg/dL usually doesn’t need repletion
• For dialysis/severe CKD: consider repleting only halfway (if 1.2 then replete up to 1.6 instead of 2.0)
• Magnesium oxide PO: 400mg raises Mg by about 2.0-2.5 mg/dL (max 800mg at a time, causes diarrhea)
• Magnesium sulfate IV: 1gm raises Mg by 0.1 mg/dL (max 4mg at a time, every 1gm IV takes 1 hour to infuse)

DVT Prophylaxis

• Option 1: heparin subcutaneous 5000 units every 8 hours (for those who could bleed and only want an every 8 hour drug onboard or CrCl < 30)
• Option 2: Lovenox (enoxaparin) subcutaneous 40mg daily (for those with normal kidneys and low likelihood to bleed)
• Option 3: mechanical prophylaxis (intermittent or sequential compression devices, for those who are bleeding)
• Option 4: nothing more because already on a treatment-dose anticoagulant