General

Management of
Patient in ICU
Part - 1

Developed by
Critical Care Nurses Society

Critical Care Nurses Society

is an association of Critical Care
Nurses who are charged with
the responsibility of caring for
acutely and critically ill patients.
The society is dedicated to
providing the members with the
knowledge and resources
necessary to provide optimal
care to critically ill patients.

CCNS is an oasis for Critical

care nurses who want to step
up their involvement and make
a difference for themselves and
their profession.

www.criticalcarenursessociety.com

We in India got the society

registered on 21.12.2011

DEFINITION

Critical Care Unit: It is a specially designed

and equipped unit of a hospital, staffed by
skilled multidisciplinary professionals to provide
holistic care to patients with actual or potential
life threatening health problems, to limit
complications, disability and restore health.

-By Critical Care Nurses Society

India

Critical Care Nursing: Critical Care Nursing is

a specialty which uses advanced competencies
to meet complex and challenging demands in
caring for critically and acutely ill patients, to
prevent complications, restore health or to
prepare for a dignified death, by assessing,
diagnosing and managing human responses to
actual or potential health problems for optimal
patient outcomes.
-By Critical Care Nurses Society
India

CONCEPTS:
Intensive Care Unit
ICU is highly specified and sophisticated area of
Set Up
a hospital which is specifically designed, staffed,
located, furnished and equipped, dedicated to
management of critically sick patient, injuries or
complications.

It is a department with dedicated medical,

nursing and allied staff.

It operates with defined policies; protocols and

procedures should have its own quality control,
education, training and research programs.

Core Components to Set Up

ICU
an
Initial
Planning
Team Formation and Leader/
Coordinator
Data Collection and analysis
Beginning of the Process and decide about
Budget allocation, aims and objectives

Decision About ICU Level, Number of

Beds, Design and Future Thoughts

Planning level of ICU like Level I, Level II or Level

III or Tertiary Unit

Number of beds and number of ICUs as needed

for the institution - Ideally 8 To 12 Beds

Designing each bed lay out and providing

optimum space for the same - 125 to 150 sqft
area per bed

Beds should be specially

designated for RRT (HD/CRRT)

Modulation according to various types of

space availability
10% of beds ( 1 or 2 ) rooms may be used
exclusively as isolation cases like for burns,
serious contagious infected patients
Central Nursing Station designing and
planning
Location, space, FacilitiesICU should be located in close proximity of
ER, Operating rooms, trauma ward Should
be single entry/exit point to ICU, which
should be manned

EQUIPMENT

Will depend on number of beds, target level of the

ICU

Most important decisions will be No. of Ventilated

beds and Invasive monitoring

ICU Vs. High Dependency Unit

Collecting information about

various equipment available with specifications

List of Essential Equipment

ICU bed
Cardiac Monitors
Ventilators Invasive,
Non Invasive
AMBU with masks
Defibrillators
IABP
Syringe Pumps
Head-end Panel
Over bed table
ABG machine
Crash Cart/ Resuscitation
Trolley
Bronchoscpoe

Pulse oxymeter
Spine board
Refrigerator
Computers
Hemodialysis machine
CRRT
Sequential Compression
Device
Airbeds
Intubating Videoscope
Glucometer
USG, Echo, X ray machine
Air beds
Thermoregulator blankets

Environmental Planning

Effective steps and planning to control nosocomial

infections
Flooring, walls, pillars and ceilings
Lighting
Access to outside natural light is recommended
by regulatory authorities in USA
High illumination and spot lighting is needed for
procedures, like putting Central lines etc.

Waste disposal and pollution control

It

is important that all govt. regulations be strictly

complied with.
It

is mandatory to have four covered pans (Yellow,

blue, Red, Black) provided for each patient or may

be one set between two patients. This is needed to
dispose off different grades of wastes.

Hand Hygiene and Prevention of Infection

Protocol about allowing visitors, shoes etc. inside ICU

ICU TEAM
Doctors, Nurses, Respiratory Therapist, Computer
Programmer, and support staff like Clerks, X-ray
technician, Lab technicians, Cleaning staff who are
trained to the needs of ICUs.
Meeting the needs of families and visitors
Signages--Clearly marked and multi linguistic
including English
Waiting and seating space- Many guidelines
suggest that l l/2 to 2 seats per patient bed be provided
in the waiting area. Enough number of restrooms
should be provided.

POLICIES &
PROTOCOLS

Admission, Discharge & Withdrawal of Support.

Legal & Ethical Guidelines & MLC Policies
Standing Orders.
Organ Donation.
Infection Control, Surveillance
Sterilization & Disinfection
Quality Control & Auditing
Isolation protocols
Bereavement & after care services
Counselling
Last office ,Support systems for patient relatives &
staff

INFECTION
CONTROL

INFORMED
CONSENT
Informed consent
permission

before

is

process

conducting

for

getting

healthcare

intervention on a person. A health care provider

may ask a patient to consent to receive therapy
before providing it, or a clinical researcher may
ask a research participant before enrolling that
person into a clinical trial.

ORGAN DONATION

Organ donation is the donation of biological tissue

or an organ of the human body, from a living or
dead person to a living recipient in need of a
transplantation. Transplantable organs and tissues
are removed in a surgical procedure following a
determination, based on the donor's medical and
social

history,

transplantation.

of

which

are

suitable

for

FAST HUGS BID

Principles of Critical Care Nursing

Early diagnosis/ Identification of problems

Prompt treatment
Anticipate complications
Considerate use of technology
Holistic approach
Recognize limits of critical care
Patient autonomy
Justice
Beneficence
Non-maleficence
Veracity

DRUGS & INFUSIONS IN

A ICU
number of emergency drugs are routinely used
in a place like ICU. Infusions, its dilution strengths
and

label

institution.

colours

vary

Generally

all

from

institution

inotropic

to

infusions,

Cordarone, are diluted in Dextrose 5%, Sedatives

either used neat or diluted in normal saline,
antibiotics are diluted as per the compatibilities.

CARDIOVASCULAR DRUGS
Inotropes

Catecholamines, e.g. Epinephrine,

Norepinephrine, Dobutamine, Dopamine

Phospodiesterase inhibitors, e.g. Milrione

Cardiac glycosides, e.g. Digoxin

CARDIOVASCULAR
Anti Arrhythmic Drugs
DRUGS

Class I A Anti Arrhythmics: Quinidine, Procainamide

and Disopyramide.

Class I-b Antiarrhythmics: Lidocaine , Mexilitine And

Tocainide.

Class I-c Anti Arrhythmics: Flecainide , Propafenone

Class II Antiarrhythmics: Acebutolol, Atenolol,

Bisoprolol, Esmolol, Metoprolol, And Propanolol.

Class III Antiarrhythmics: Amiodarone

Class IV Antiarrhythmics: Diltiazem, And Verapamil.

Class V Others: Atropine, Digoxin

CARDIOVASCULAR
DRUGS
Vasodilators
Angiotensin converting enzyme (ACE)
inhibitors: captopril, enalapril, ramipril.
Angiotensin receptor blockers (ARBs):
Telmisartan, Valsartan, losartan, olmesartan
Calcium-channel blockers (CCBs):
Amlodipine, nicardipine, nifedipine,
Verapamil, Diltiazem
Beta Blockers: Acebutolol, Atenolol,
Bisoprolol, Metoprolol, Nebivolol, Propranolol
Nitrates: Nitroglycerin
Alpha Blockers: Doxazosin, Prazosin,
Terazosin

COMMON DRUGS
ADRENALINE (EPINEPHRINE)

Classification: Sympathomimetic, Alphaadrenergic agonist, Beta1- and beta2adrenergic agonist, Cardiac stimulant,
Vasopressor, Bronchodilator
Dose and Route: 0.51mg (510mlof
1:10,000 solution) IV during resuscitation,
0.5mg q5 min.
Action: Vasoconstriction, contraction of dilator
muscles of iris. positive chronotropic and
inotropic effects on the heart, bronchodilation,
vasodilation, and uterine relaxation
Indication
Cardiac arrest ,AV heart block with syncopal
seizures, syncope due to carotid sinus

ADRENALINE (EPINEPHRINE) Cont

Side

effects

CNS: Fear, anxiety, restlessness, headache, lightheadedness, dizziness, drowsiness

CV: Arrhythmias, hypertension resulting in

intracranial hemorrhage, CV collapse with
hypotension, palpitations, tachycardia

GI: Nausea, vomiting, anorexia

GU: Constriction of renal bloood vessels and
decreased urine formation and dysuria

Local: Necrosis at the site of repeat injections.

NOR-ADRENALINE (NOREPINEPHRINE)
CLASSIFICATION: Sympathomimetic,
Alpha-adrenergic agonist,

ACTION: Stimulates alpha 1 and beta 1 receptors in

the sympathetic nervous system causing
vasoconstriction and cardiac stimulation.

INDICATION
cardiac arrest and profound hypotension.

CONTRAINDICATIONS: Hypovolemia,Ventricular
fibrillation, Tachydysrrhythmia, Pheochromocytoma,
Hypotension, Contraindicated in patients during
cyclopropane and halothane anesthesia.

NOR-ADRENALINE Cont
Adverse effects:

CNS: Headache , anxiety, insomnia

CV: thrombophlebitis, pulmonary embolism,

thrombotic disorders, ectopic beats,
tachycardia, severe hypertension

Respiratory: dyspnea

Skin: rash with or without pruritus, necrosis,

tissue sloughing, gangrene

GI: Nausea, vomiting

DOPAMINE

Drug

class:

Sympathomimetic,

Alpha

adrenergic agonist

Action
Drug acts directly and by the release of
norepinephrine
terminals;

from

dopaminergic

sympathetic
receptors

nerve
mediate

dilation of renal and splanchnic beds, which

maintains renal perfusion and function; alpha
receptors, which are activated by higher doses
of dopamine, mediate vasoconstriction, which

DOPAMINE Cont..
Indications
Correction of hemodynamic imbalance in shock,
endotoxic septicaemia, open heart surgery, renal
failure and chronic cardiac decompensation in CHF
Contraindication
Pheochromocytoma, tachyarrhythmias,
hypovolemia.
Side Effects
CVS: ectopic beats, tachycardia, angina pain,
palpitations, hypotension, vasoconstriction,
dyspnoea, bradycardia, hypertension, widened
QRS complex.

DOBUTAMINE

Classification: Inotropic agent

Mode of action: stimulation of beta receptors of the

heart while producing comparatively hypertensive,
arrhythmogenic and vasodialation effects.
Causes an increase in cardiac output (C.O) usually not
associated with a marked increase in heart rate, while
the stroke volume is usually increased.

Indications: Severe cardiac failure secondary to AMI or

cardiomyopathy, Cardiogenic shock, Septic shock,
Congestive cardiac failure, Acute pulmonary oedema.

DOBUTAMINE Cont.
Available dose: I.V injection: 12.5 mg/ml in
20 ml vial (250 mg)
Contraindications
Idiopathic hypertrophic sub aortic stenosis
Adverse /side effects
CNS: headache, tremors, paresthesias,
mild leg cramps, nervousness, fatigue
(with overdosage).
CV: increased heart rate and BP,
premature ventricular beats, palpitation,
anginal pain. GI: nausea, vomiting.
Other: nonspecific chest pain, shortness of

ATROPINE
Classification Anticholinergic, Antimuscarinic
Mode of action
Competitively blocks the effects of acetylcholine at muscarinic
cholinergic receptors that mediate the effects of parasympathetic
postganglionic impulses, also blocks the effects of acetylcholine in
the CNS.
Indication
Treatment of parkinsonism; relieves tremor and rigidity
Restoration of cardiac rate and arterial pressure during
anesthesia, lessening the degree of AV block when increased
vagal tone is a factor (eg, some cases due to digitalis)

ATROPINE Cont
Adverse effects

CNS: Blurred vision, mydriasis, cycloplegia,

photophobia,
increased
IOP,
headache,
flushing, nervousness, weakness, dizziness,
insomnia, mental confusion or excitement
CV: Palpitations, bradycardia (low doses),
tachycardia (higher doses)
GI: Dry mouth, altered taste perception,
nausea,
vomiting,
dysphagia,
heartburn,
constipation, bloated feeling, paralytic ileus,
gastroesophageal reflux
GU:
Urinary
hesitancy
and
retention;
impotence
Systemic:
Systemic
adverse
effects,

Vasopressin (Pitressin,
Vasoptin)
Classification: Hormones, Antidiuretic
hormones, vasopressor
Available as Injection: 20 units / ml
Action
Alters the permeability of the renal collecting
ducts, allowing reabsorption of water.
Directly stimulates musculature of GI tract.
In high doses acts as a non-adrenergic
peripheral vasoconstrictor.
Decreased urine output and increased urine
osmolality in diabetes insipidus.

VASOPRESSIN
Cont.
Indications
Central diabetes insipidus due to deficient
antidiuretic hormone, Management of
pulseless VT/ VF Gastrointestinal hemorrhage.
Side Effects

CNS: dizziness, "pounding" sensation in head.

CV: MI, angina, chest pain.
GI: abdominal cramps, belching, diarrhea,
flatulence, heartburn, nausea, vomiting.
Dermatology: paleness, peri-oral blanching,
sweating.
Miscellaneous: allergic reactions, fever,
water intoxication (higher doses).

Nursing Responsibility
(Cardiovascular Drugs)

Hourly vitals, continuous hemodynamic monitoring

Administer IV infusions into a large vein, preferably

the antecubital fossa, to prevent extravasation.

Adjust flow rate to maintain BP at normal (usually

80100 mm Hg systolic) in normotensive patients.
In previously hypertensive patients, systolic is
generally maintained no higher than 40 mm Hg
below pre existing systolic level.

Observe carefully and record mental status (index of

cerebral circulation), skin temperature of

NURSING RESPONSIBILITY
Cont.

Monitor I&O. Urinary retention and kidney shutdown

are possibilities, especially in hypovolemic patients.
Urinary output is a sensitive indicator of the degree
of renal perfusion. Report decrease in urinary
output or change in I&O ratio.

Be alert to patients complaints of headache,

vomiting, palpitation, arrhythmias, chest pain,
photophobia, and blurred vision as possible
symptoms of overdosage. Reflex bradycardia may
occur as a result of rise in BP.

DRUGS FOR RESPIRATORY SYSTEM

Drugs that are used for treatment of respiratory problems include
1. Drugs & air flow obstruction.

2. Oxygen.
3. Respiratory stimulants.
4. Expectorants & cough suppressant.

B2 - Adrenoceptors Agonists or Stimulants:

Salbutamol: Salbutamol has a relativity long duration of action
of about 4 hours or even longer.
Mechanism of action:

Agents as salbutamol, terbutaline and fenoterol are selective

stimulants of B2 receptors; they act on these receptors in
bronchi and small airways and on mast cells.

They cause fewer side effects on heart than adrenadine or

isoprenaline which are non-selective (obsolete).

SALBUTAMOL CONT.
INDICATION:
Asthma, Chronic obstructive airways disease (long-term treatment
and prophylactic), or maintenance therapy (aerosol or oral tablets)
or in acute attacks by nebulizers.
CONTRAINDICATION:
Hypersensitivity
SIDE EFFECT:
1. Tremor due to Stimulation of B2 receptors.
2. Other does-dependent effects resulting from weak activation of Breceptor as tachycardia and hypokalemia, these are rare however
with higher degree of selectivity afforded by aerosol route.

AMINOPHYLLIN
E: of theophylline and ethylene diamine in ratio of 2:1 It is
It consists
used in:
1. Severe acute attacks of asthma & status asthmatics.
2. Exacerbation of COPD.
3. Acute left ventricular failure with pulmonary edema.
Oral theophylline preparations are useful in long-term treatment of
asthma & reversible (COPD). A useful bronchodilation response
can be often achieved with in the therapeutic range & the S/E can
be minimized with the aid of plasma level measurements.

Mast Cell Membrane Stabilizers:

They are not bronchodilators but they prevent bronchoconstriction in

patient with extrinsic (allergic) asthma which is caused by pollen &
allergic agents.

They stabilize sensitized mast cell and inhibit the release if

bronchoconstrictor agent like: histamine,(serotonin) & leukotrines.

Mast cell stabilizers are useful in extrinsic (Allergic) asthma

particularly in children & young adults & can prevent exercise
induced asthma.

Response in intrinsic asthma is usually disappointing and these

agents have nothing to offer to patients with (COPD).

CORTICOSTEROIDS
The effects are as follows
a. Anti-inflammatory (for any reason).
b. Reduction of mucosal oedema increase airflow.
c. Modification of immune response & stabilization of mast cells.
d. Increase B2 - receptor responsiveness to agonist

Anti-cholinergic
Drugs:
IPRATROPIUM
Mechanism
of action:

The parasympathetic cholinergic bronchoconstrictor effect can be

blocked by the use of atropine like drugs, usually this effect of
anticholinergic on airway resistance

Dosage and Administration

Adults
Aerosol/Inhalation 2 inhalations 4 times daily.
Do not exceed 12 inhalations in 24 h. Solution 500mcg (1 unit
dose vial) administered 3 to 4 times a day by oral nebulization,
with doses 6 to 8 h apart.

NURSES RESPONSIBILITY
(RESPIRATORY SYSTEM )

Assess lung sounds, pulse, and blood pressure before

administration and during peak of medication. Note amount, color,
and character of sputum produced.
Monitor pulmonary function tests before initiation therapy and
periodically throughout course to determine effectiveness o
medication.
Observe for paradoxical bronchospasm (wheezing). If condition
occurs, withhold medication and notify physician or other health
care professional immediately.
Instruct patient to take medication exactly as directed. If on a
scheduled dosing regimen , take missed dose as soon as
remembered, spacing remaining dose at regular intervals

Nurses Responsibility

Cont

Instruct patient to conduct health care professional immediately if

shortness of breath/Dyspnoea is not relieved by medication or is
accompanied by diaphoresis, dizziness, palpitations, or chest pain.
Advise patient to consult health care professional before taking any
OTC medications or alcohol concurrently with this therapy. Instruct
patient in the proper use of the metered- dose inhaler, Rotahaler, or
nebulizer.
Advise patients to use albuterol first if using other inhalation
medications and allow 5 min to elapse before administering other
inhalant medications unless otherwise directed.
Advise patient to rinse mouth with water after each inhalation dose to
minimize dry mouth.

SEDATIVES AND
ANALGESICS
Classification:

Barbiturates - Pentobarbital,
Phenobarbitol

Benzodiazepines Clonazepam,
Diazepam, Lorazepam , Midazolam,
Alprazolam

Muscle Relaxants

Neuromuscular blockers

MORPHINE
SULPHATE
Action
Principal opium alkaloid; acts as agonist at
specific opioid receptors in the CNS to
produce analgesia, euphoria, sedation
Indications
Relief of moderate to severe acute and
chronic
pain
Preoperative medication to sedate and allay
apprehension, facilitate induction of
anesthesia
and reduce anesthetic dosage

MORPHINE SULPHATE Contd

CNS:Light-headedness, dizziness,
sedation,euphoria,dysphoria, delirium, insomnia,
agitation, anxiety, fear, hallucinations, disorientation,
drowsiness, lethargy

CV:Facial flushing, peripheral circulatory collapse,

tachycardia,bradycardia

Dermatologic:Pruritus,urticaria,laryngospasm,
bronchospasm,edema

GI:Nausea, vomiting,dry mouth, anorexia,

constipation,biliarytract spasm; increased colonic
motility in patients with chronic ulcerative colitis

FENTANY
L
Action
Acts at specificopioidreceptors, causing
analgesia, respiratory depression, physical
depression, euphoria.
Indications
Analgesic action of short duration during
anesthesia and immediate postoperative
period
Analgesic supplement in general or regional
anesthesia
Administration
with
aneurolepticas
an
anestheticpremedication, for induction of
anesthesia, and as an adjunct in maintenance

FENTANYL
Cont.
Adverse Effects

CNS:Sedation,
clamminess,
sweating,
headache, vertigo, floating feeling, dizziness,
lethargy, confusion, light-headedness,
CV:Palpitation, increase or decrease in BP,
circulatory depression,cardiac-arrest,
shock, tachycardia,bradycardia,
arrhythmia, palpitations
Dermatologic:Rash,
hives,pruritus,
flushing, warmth, sensitivity to cold
EENT:Diplopia, blurred vision
GI:Nausea, vomiting,dry mouth, anorexia,
constipation,biliarytract spasm

LORAZEPA
M
Available forms
Injection2, 4mg/mL; oral solution2 mg/mL;
tablets0.5, 1, 2mg
Action: They are a group of anxiolytics,
antiepileptics, muscle relaxants and sedative
hypnotics. Benzodiazepines potentiate the effect
of gamma amino butyrate an inhibitory
neurotransmitter.
Indication:
Management of anxiety disorders, short term
relief symptoms of anxiety.
Short term treatment of insomnia.
Akinetic or myoclonic seizures.

LORAZEPAM
Cont.
Side effects

CNS: Transient mild drowsiness initially,

sedation, depression, lethargy, apathy,
fatigue, light headedness, disorientation,
CV: Bradycardia, tachycardia, CV collapse,
hypertension and hypotension, palpitations
and trauma.
DERM: Urticaria, pruritus, skin rash,
dermatitis.
EENT: visual and auditory disturbances,
diplopia, nystagmus, nasal congestion.
GI: Constipation, diarrhoea, dry mouth,
salivation, nausea, anorexia, vomiting.
GU: Incontinence, urinary retention, changes

NURSES
RESPONSIBILITY
Teach
to:

Take drug exactly as prescribed; do not stop

taking drug) without consulting health care
provider.
These side effects may occur: Drowsiness,
dizziness (may be transient; avoid driving or
engaging in dangerous activities); if used as a
sedative and hypnotic; depression, dreams,
emotional upset, crying.
Report severe dizziness, weakness, drowsiness
that persists, rash or skin lesions, palpitations,
edema of the extremities; visual changes;
difficulty voiding.
Keep this and all medications out of the reach of
children.

ANTICOAGULANTS
HEPARIN
Action:
- Potentiates the inhibitory effect of anti
thrombin on factor Xa and thrombin. In low doses,
prevents the conversation of prothrombin to
thrombin by its effects on factor Xa. Higher doses
neutralize thrombin, preventing the conversation of
fibrinogen to fibrin .
Indication: - Prophylaxis and treatment
of various thromboembolic disorders
including: - Venous thromboembolism
pulmonary emboli, atrial fibrillation
with embolization

HEPARIN Cont.
Adverse Reaction and Side Effects

GI: Drug induced hepatitis.

DERM: alopecia (long term use), rashes, urticaria.

HEMAT: bleeding, anemia, thrombocytopenia.

LOCAL: pain at injection site.

MS: Osteoporosis (long term use)

MISC: fever, hypersensitivity.

ANTIDOTE: Protamine sulfate

WARFARIN
ACTION: Interferes with hepatic synthesis of vitamin K dependent
clotting factors (II, VII, IX, and X).
INDICATION : Prophylaxis and treatment of venous thrombosis ,
pulmonary embolism , Atrial fibrillation with embolization ,
management of myocardial infarction , CONTRAINDICATION :
Uncontrolled bleeding , open wound , active ulcer disease ,recent
brain ,eye, or spinal cord injury or surgery , severe liver disease ,
DOSAGE
Tablets :1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg
ANTIDOTE: Vitamin K

Low Molecular Weight Heparins

(LMWH)
These
include drugs such asenoxaparin,
dalteparin, These
heparin and have
standard heparin.

drugs are derived from

some benefits over the

ACTION

They inhibit only clotting factor Xa and reduce

platelet levels less frequently. Thus they could
cause less bleeding.

They are better absorbed from a

subcutaneous injection.

(LMWH)
CONT.

ROUTE: Subcutaneous.
DOSE: 60mg, 80mg, 100mg, 120mg and 150mg
graduated syringes.
SIDE EFFECTS:
Bleeding (nosebleeds, gum bleeds, excessive
bruising)
Irritation at the injection site can occur in some
patients.
Fatal, allergic reactions, injection site reactions,
and increases in liver enzyme tests,
Decrease in platelet count, a complication
known as Heparin Induced Thrombocytopenia.

Role Of Nurse In
Administration Of
Anticoagulants
Obtain a complete health history including recent

surgeries or trauma, allergies, drug history, and

possible drug interactions.
Obtain vital signs
Monitor for adverse clotting reaction(s).
Observe for skin necrosis, changes in blue or
purple mottling of the feet that blanches with
pressure or fades when the legs are elevated.
Use with caution in clients with GI, renal and/or
liver disease, alcoholism, diabetes, hypertension,
hyperlipidemia, and in the elderly and
premenopausal women.

NURSING RESPONSIBILITY Cont.

Monitor for signs of bleeding: flulike symptoms,

excessive bruising, pallor, epistaxis, hemoptysis,
hematemesis, menorrhagia, hematuria, malaena, frank
rectal bleeding, or excessive bleeding from wounds or in
the mouth.

Monitor laboratory values: APTT and PTT for therapeutic

values. (Heparin may cause significant elevations of
aspartate aminotransferase (AST) and alanine
transaminase (ALT), because the drug is metabolized by
the liver)

Monitor CBC, especially in premenopausal women.

(Changes in CBC may indicate excessive bleeding.

End of Part 1