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Vasoactive Drips: A Guide to Starting and Titrating Critical Care Drips

2 Contact Hours including 2 Advanced Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Friday, April 3, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will have increased knowledge and confidence in their ability to administer vasoactive intravenous medications safely.

Objectives

After completing the course, the participant will be able to:

  1. Explain when vasoactive medications are indicated.
  2. Identify the parameters and titration of critical care medications.
  3. Define titration, vasopressor, inotrope, catecholamine, adrenergic, vasodilator, and antiarrhythmic.
  4. Determine vasoactive drugs, infusion rates, and other medicines for critically ill patients.
  5. Specify how to calculate and verify drug mixtures every time a critical drug is administered.
  6. Outline the basic principles of administering vasoactive medications to the pediatric patient.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Vasoactive Drips: A Guide to Starting and Titrating Critical Care Drips
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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    James Wittenauer (RN, MSN, MPA, RN-BC)

Definitions

The following definitions are used when addressing vasoactive medications:

  • Titration: Increasing or decreasing vasoactive drug infusions for therapeutic effect (Caffrey & Borrelli, 2021).
  • Vasopressor: A drug class that induces arterial vasoconstriction and elevates blood pressure (VanValkinburgh et al., 2023).
  • Inotropes: Drugs that affect the strength of contraction of the heart muscle (myocardial contractility); negative inotropes decrease cardiac workload and blood pressure, and positive inotropes increase cardiac workload and blood pressure. Negative inotropes are beta-blockers, diltiazem, and verapamil. Positive inotropes are dopamine, dobutamine, epinephrine, and norepinephrine (VanValkinburgh et al., 2023).
  • Chronotrope: Any medication that affects the heart rate. The chronotrope may include a positive or negative response, such as Lopressor or Cardizem for a negative chronotrope or dobutamine, which can be positive (VanValkinburgh et al., 2023).
  • Catecholamine: Any class of aromatic amines that includes several neurotransmitters that cause sympathomimetic action, such as epinephrine, norepinephrine, dopamine, and dobutamine (VanValkinburgh et al., 2023).
  • Adrenergic: Having characteristics of secreting epinephrine or substances with similar activity, such as epinephrine and norepinephrine (Farzam et al., 2023).

It should be noted that medications can be classified into multiple classes: chronotropic, inotropic, or vasodilator.

Introduction

Vasoactive medications are indicated when the systolic blood pressure (SBP) has a decrease of > 30 millimeters of mercury (mmHg) from the baseline or a mean arterial pressure (MAP) less than 60-65 mmHg and when the condition results in end-organ dysfunction due to hypoperfusion. Additionally, vasoactive medications are used to manage a hypertensive crisis, flash pulmonary edema, sepsis, shock states, atrial fibrillation with a rapid ventricular response, supraventricular tachycardia, heart failure, and hemodynamically unstable patients.

Vasopressors should be infused via central access but can be administered peripherally until central access is obtained. It should also be noted that the intraosseous (IO) route is a growing trend due to the ease of use of the site in emergent situations (Perkins & Couper, 2023); however, there are certain risks involved, including misplaced IO catheter and questionable absorption of the medication once given. All vasoactive drips can cause severe tissue injury if infiltration occurs. Having arterial line pressure monitoring for patients on vasoactive drips should also be considered. A physician's order is needed to administer any vasoactive drip, and the order should include parameters to titrate related to heart rate and/or blood pressure. Healthcare providers must know the maximum dose, the minimum dose, the titration parameters, and the side effects of all critical care drips and infusions.

Remember that cardiac output is the holy grail of hemodynamics. Cardiac output must be sustained to maintain blood pressure and heart rate. Cardiac output is defined by the stroke volume times the heart rate (SV x HR). Cardiac output is vital for oxygen delivery, blood pressure, urine output, and end-organ perfusion.

Many drugs are used for hemodynamic instability, cardiogenic shock, and neurogenic shock. Medications include norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, and dobutamine. The previous practice of correcting volume loss before the administration of vasopressors, at least in the context of sepsis, is not as prevalent due to the conflicting evidence of its efficacy (MacDonald et al., 2022), and even to the detriment of the patient (Pinsky et al., 2022). However, MacDonald et al. (2022) suggest tailoring intravenous (IV) fluids to each patient and close hemodynamic monitoring to determine the efficacy of the vasoactive drip and eventually lessen the duration they are used (Pinsky et al., 2022). Vasoactive drips will only temporarily correct hypovolemia, and then the patient will become unstable again until the patient's fluid volume status is corrected. All critical care drips must be on an infusion pump. All patients on vasoactive medications must be on a continuous heart monitor, blood pressure, and oxygen saturation monitoring (VanValkinburgh et al., 2023). Since patients who receive vasoactive medication are in a specialty care area, emergency resuscitative equipment and medications will always be immediately available to manage any unwanted medication reactions.

Vasoactive Drip Calculations

photo of iv drip

IV Drip

Here is the basic equation for formulating, mixing, and calculating drip rates. For this exercise, a consistent patient weight of 75 kilograms (kg) will be used for all calculations.

The following formula can be used for all critical care medications using only the applicable elements. If the drug ordered is microgram per minute (mcg/min), then omit the kg element (Rady Children's Hospital-San Diego, 2008).

Ordered amount of drug x patients' weight in kg x 60 minutes/Drug concentration (milligram [mg] divided by milliliter [mL]) then multiplied x 1000 for mcg.
Equals (=) ml/hour (hr).

Examples of drug calculations will be shown after medication definitions, dosing, and titration instructions.

Vasopressors and Inotropes

Levophed

Levophed (norepinephrine) is a potent alpha/beta-agonist causing vasoconstriction and increased blood pressure. It is used for severe hypotension, shock, or bradycardia and is now considered a first-line agent for shock, including septic shock, according to De Backer et al. (2022). The pressor is mixed as 4 mg Levophed in 250 ml of dextrose 5% in water (D5W), making the drip 16 mcg/ml. The standard effective dose is 2-12 mcg/minute (min). Levophed has a rapid onset and short half-life. The drip is usually started at 2 mcg/min or 7.5 ml/hr and titrated up for effect or until blood pressure becomes normotensive with a MAP of 60-65 mmHg or SBP > 90. Vital signs are monitored continuously and documented every five minutes during titration.

LEVOPHED CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose Ordered 
mcg/min
Levophed
4 mg/250 ml
Special Instructions
0.51.9 ml/hrProtect from light
13.8 ml/hrTitrate up every 20 min
27.5 ml/hrIncompatible with Sodium bicarbonate
(NaHCO3)
311.3 ml/hImmediate onset
415 ml/hrHalf-life 1-2 minutes
518.8 ml/hrCan cause arrhythmias
622.5 ml/hrIncreases cardiac oxygen needs
726.3 ml/hrUse phentolamine for extravasation
830 ml/hrCauses vasoconstriction
933.8 ml/hrDo not use with hypovolemia
1037.5 ml/hrDo not use with monoamine oxidase inhibitors
(MAOI) therapy
30112.5 ml/hrCocaine use causes hypertension

Scenario

A 54-year-old (y/o) male presents to the emergency room (ER) complaining of feeling weak and dizzy. He has a history of gout, diabetes, gastroesophageal reflux disease (GERD), and psoriasis. He is allergic to sulfa. His glucose is 96. He is pale, clammy, and lethargic. His vital signs are a heart rate of 101, blood pressure of 78/50 mmHg, oxygen saturation of 94%, temperature of 97.8, and respirations of 24. A 16 gauge (16g) peripheral IV is established, an electrocardiogram (ECG) is completed (sinus tachycardia), and oxygen therapy 3 liters (L) nasal cannula (NC) is started. After 3 L of normal saline (NS), his blood pressure is 80/40. Which medication should the doctor order?

  1. Dopamine
  2. Dobutamine
  3. Levophed
  4. Diltiazem

Rationale:

Levophed (norepinephrine) is an alpha/beta-agonist, causing vasoconstriction and increased blood pressure. It is used for severe hypotension, shock, or bradycardia. Dopamine and dobutamine are contraindicated with a sulfa allergy.

The physician orders a Levophed drip to be started at 0.5 mcg/min with parameters ordered to keep SBP > 90 and heart rate less than 120. After 20 minutes, the patient's vital signs were a heart rate of 106, blood pressure of 88/42, and saturation of 96%. What is the subsequent titration?

  1. 10 mcg/min
  2. 5 mcg/min
  3. 3 mcg/min
  4. 1 mcg/min

Rationale:

Levophed has a rapid onset and short half-life. Incremental increases in the drip will improve blood pressure rapidly. Monitor the vital signs every five minutes and increase the drip after 20 minutes if necessary to meet the parameters.

Epinephrine

Epinephrine is used for profound refractory hypotension, ventricular fibrillation (VF), ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole. It is the first drug of choice for cardiac arrest. It is a vasopressor and sympathomimetic drug that increases coronary perfusion. Mix 1 mg epinephrine in 250 ml NS or D5W. The infusion is started at 1-4 mcg/min and titrated up for effect. The usual dose is 2-10 mcg/min. It is a very quick-acting drug with an extremely short half-life. It can be titrated up by 1-2 mcg/min every 20 minutes until the desired effect or hemodynamic stability. However, more is not better. High doses do not improve outcomes and can cause post-resuscitation myocardial dysfunction. Epinephrine can cause hyperglycemia, so glucose levels should be monitored. It can also cause decreased urine output and metabolic acidosis.

EPINEPHRINE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose ordered
mcg/min
Epinephrine
1 mg/250 ml (4 mcg/ml)
Special Instructions
115 ml/hrOnset immediate
230 ml/hrHalf-life 1-2 min
345 ml/hrDo not give with alkaline solutions
460 ml/hrCan cause hypertension and arrhythmias
575 ml/hrMonitor pulses with vasoconstriction
690 ml/hrHigh doses can cause myocardial ischemia
7105 ml/hrKeep the patient on a cardiac monitor
8120 ml/hr 
9135 ml/hr 
10150 ml/hr 

Scenario

A 70 y/o male presents to the ER via ambulance with profound hypotension. He has no vital signs and is in asystole. He has agonal respirations. No IV access is established. Upon arrival, the ER team begins CPR, administering oxygen with a bag-mask bag and starting a peripheral IV. What is the BEST drug of choice for this patient?

  1. Amiodarone
  2. Dopamine
  3. Heparin
  4. Epinephrine

Rationale:

Epinephrine is used for profound refractory hypotension, VF, VT, PEA, and asystole. It is the first drug of choice for cardiac arrest.

The patient is transferred to the intensive care unit (ICU), and the hospitalist in the ICU orders an epinephrine drip to start at 2 mcg/min. The patient is 90 kg and 5 feet 4 inches. His glucose is 94. He is lethargic and pale. He is now intubated and on a ventilator. His oxygen saturation is 94%. He has adequate urine output. The pharmacy brings you epinephrine 1 mg in 250 ml of D5W. What is the rate of the infusion in ml/hr?

  1. 35
  2. 60
  3. 30
  4. 90

Rationale:

EXAMPLE: The physician orders epinephrine 2 mcg/min titrate for SBP > 100, heart rate > 80, and heart rate < 110.

This medication is mixed at the bedside. Epinephrine 1 mg is added to 250 ml D5W.

Ordered amount of drug x patients weight in kg x 60 minutes/Drug concentration (mg divided by ml) then multiply x 1000 for mcg
= ml/hr
2 mcg x 60/1/250 x 1000 (4 mcg/ml)

30 ml/hr

Here is an explanation of each element:

2 mcg is the order of the Epinephrine

The weight in kg is omitted as the medication is NOT weight-based.

Epinephrine is a vasopressor and sympathomimetic drug. It has an immediate onset and a 1-2 min half-life. Some of the special precautions include which of the following?

  1. Hyperglycemia, hypertension, arrhythmias
  2. Hypoglycemia, renal failure, seizures
  3. Vasodilation, hypotension, liver toxicity
  4. Neurotoxicity, arrhythmias, hypoglycemia

Rationale:

Epinephrine can cause hyperglycemia, so glucose levels should be monitored. It can also cause hypertension and arrhythmias.

Epinephrine is the first drug of choice for cardiac arrest. It is a vasopressor and will increase coronary perfusion. This drug starts at 10 mcg/min and is rapidly titrated up for effect to 20 mcg/min. High doses improve patient outcomes after PEA and asystole. Is this true or false?

  1. True
  2. False

Rationale:

Epinephrine infusion is started at 1-4 mcg/min and titrated up for effect. The usual dose is 2-10 mcg/min. It is a very quick-acting drug with an extremely short half-life. It can be titrated up by 1-2 mcg/min every 20 minutes until the desired effect or when hemodynamic stability is achieved. However, more is not better. High doses do not improve outcomes and can cause post-resuscitation myocardial dysfunction.

Premixed Dopamine

Dopamine is an adrenergic agonist for central hypotension, heart failure, and increased renal and mesenteric perfusion without hypovolemia. It is an endogenous catecholamine precursor of norepinephrine. Dopamine was used as a first-line agent but is no longer considered a first agent. It is a positive inotrope with vasoconstrictive actions. It tends to exhibit beta-agonist qualities in low doses. In higher doses, it acts more like an alpha-agonist and will increase cardiac output and heart rate, augmenting cardiac performance. Lower doses will improve renal perfusion in shock and sepsis situations.

Dopamine usually comes mixed as 400 mg in 250 mL D5W, equaling 1600 mcg/ml. The onset of action is five minutes, and the half-life is two minutes. The dose is 2-20 mcg/kg/min. It usually starts at 5 mcg/kg/min. Dopamine is contraindicated in patients with sulfate allergy. It can cause significant tachycardia, so it is imperative to have continuous cardiac monitoring. It can also cause vasoconstriction, limb ischemia, and widened QRS complex. Urine output should be monitored hourly. The maximum dose is 20 mcg/kg/min. The chart below is based on Dopamine 400 mg/250 ml D5W.

DOPAMINE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose ordered mcg/kg/min75kg80kg85kg90kg95kg100kg
514ml/hr15ml/hr16ml/hr17ml/hr18ml/hr19ml/hr
7.521ml/hr23ml/hr24ml/hr25ml/hr27ml/hr28ml/hr
1028 ml/hr30ml/hr32ml/hr34ml/hr36ml/hr38ml/hr
1542 ml/hr45ml/hr48ml/hr51ml/hr53ml/hr56ml/hr
2056 ml/hr60ml/hr64ml/hr68ml/hr71ml/hr75ml/hr

Scenario

A 54 y/o female in the ICU starts to have a decrease in blood pressure and urine output. Her blood pressure is 88/40, and her urine output is less than 30 ml/hr. She has received 2 L of NS and remains hypotensive. What is the best drug of choice for this patient?

  1. Epinephrine
  2. Levophed
  3. Diltiazem
  4. Dopamine

Rationale:

Dopamine is an adrenergic agonist used for central hypotension, heart failure, and increased renal and mesenteric perfusion in the absence of hypovolemia.

Dopamine is ordered for the patient at 5 mcg/kg/min. The patient has a history of diabetes and fibromyalgia. She weighs 75 kg and is 5 feet 7 inches tall. Her heart rate is 80, and her blood pressure is 90/60. The dopamine is 400 mg in 250 ml D5W. What will the infusion rate be in ml/hr?

  1. 64
  2. 32
  3. 14
  4. 26

Rationale:

EXAMPLE: The physician orders dopamine 5 mcg/kg/min titrate to keep SBP > 100 and MAP > 65.

The hospital pharmacy has premixed dopamine 400 mg/250 ml D5W. Your patient weighs 75 kg.

5 x 75 x 60/400/250 x 1000
=14.06 ml/hr
(1.6 mg/ml or 1600 mcg/ml)
 

Here is an explanation of each element:

  • 5 is the order of Dopamine 5 mcg
  • 75 kg is the patient weight
  • 60 minutes (# of minutes in an hour)
  • 400 mg of dopamine in 250 ml D5W (change mg to mcg/1 mg =1000 mcg)

Dopamine is a positive inotrope used for central hypotension. It can also increase renal perfusion. Monitoring urine is essential. The patient has no urine output for 24 hours. The doctor orders dopamine 40 mcg/kg/min. Is this the correct infusion amount?

  1. True
  2. False

Rationale:

Dopamine is an adrenergic agonist used for central hypotension, heart failure, and increased renal and mesenteric perfusion in the absence of hypovolemia. It is a positive inotrope. Dopamine is mixed with 400 mg in 250 cc/D5W, equaling 1600 mcg/ml. The onset of action is five minutes, and the half-life is two minutes. The dose is 2-20 mcg/kg/min. It is usually started at 5 mcg/kg/min.

The best adrenergic agonist for central hypotension, heart failure, and increased renal perfusion is which of the following?

  1. Dobutamine
  2. Dopamine
  3. Vasopressin
  4. Levophed

Rationale:

Dopamine is an adrenergic agonist used for central hypotension, heart failure, and increased renal and mesenteric perfusion in the absence of hypovolemia.

The same ICU patient is on a dopamine drip at 15 mcg/kg/min. Her blood pressure is 102/60. Her heart rate is 70. Her urine output is 30 ml/hr. The physician orders the drip to be titrated down by 5 mcg/kg/min every half hour as long as the SBP > 100. The drip is decreased to 10 mcg/kg/min. Forty-five minutes later, the patient has a heart rate of 110 and blood pressure is 90/58. What is the nurse's next action?

  1. Titrate the drip up to 15 mcg/kg/min.
  2. Call the physician
  3. Keep the drip at 10 mcg/kg/min
  4. Start NS intravenous fluids

Rationale:

Titrate drips according to the physician's written parameters and re-verify orders if in doubt.

Dobutamine

Dobutamine is an adrenergic agonist and first-line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts like a chemical balloon pump that reduces afterload but increases the rate and cardiac contractility. It increases cardiac output and mild vasodilation. Dobutamine will cause hypotension in the presence of hypovolemia. If hypotension occurs after infusion, stop the infusion and address fluid volume losses. Dobutamine can cause tachycardia and headaches. It is contraindicated in patients with a sulfite allergy. The onset is 1-2 minutes, and the half-life is two minutes.

Mix 500 mg in 250 ml D5W for 2000 mcg/ml. The drip is started at 1-2 mcg/kg/min and titrated up to a maximum dose of 40 mcg/kg/min.

DOBUTAMINE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose ordered mcg/kg/min75 kg80 kg85 kg90 kg95 kg100 kg105 kg
511 ml/hr12 ml/hr13 ml/hr14 ml/hr15 ml/hr16 ml/hr17 ml/hr
716 ml/hr17 ml/hr18 ml/hr19 ml/hr20 ml/hr21 ml/hr22 ml/hr
1023 ml/hr24 ml/hr26 ml/hr27 ml/hr29 ml/hr30 ml/hr32 ml/hr
1534 ml/hr36 ml/hr38 ml/hr41 ml/hr43 ml/hr45 ml/hr47 ml/hr
2045 ml/hr48 ml/hr51 ml/hr54 ml/hr57 ml/hr60 ml/hr63 ml/hr

Scenario

A 77 y/o male with diabetes and a history of hypertension presents to the ER. He is pale and cool. His glucose is 274. His heart rate is 88, his blood pressure is 72/44, and his oxygen saturation is 94%. He has a history of left ventricular heart failure. What drug do you expect the doctor to order?

  1. Vasopressin
  2. Epinephrine
  3. Dobutamine
  4. Lidocaine

Rationale:

Dobutamine is an adrenergic agonist and first-line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension.

Which drug acts as a chemical balloon pump, reducing afterload but increasing heart rate and cardiac contractility?

  1. Dopamine
  2. Epinephrine
  3. Vasopressin
  4. Dobutamine

Rationale:

Dobutamine is an adrenergic agonist and first-line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts as a chemical balloon pump, reducing afterload but increasing the rate and cardiac contractility.

After 3 L of fluid, the same patient remains hypotensive with a blood pressure of 88/42 and a MAP < 60. His urine output is 30 ml/hr. He weighs 85 kg. His oxygen saturation is 92% on a 40% face mask. He can answer questions when aroused. The patient's heart rate is 99. Dobutamine is ordered at 5 mcg/kg/min. Mix 500 mg in 250 ml D5W for 2000 mcg/ml. The infusion pump is set at 7 ml/hr. Two minutes after the infusion, the bedside cardiac monitor shows a heart rate of 126, saturation of 90%, and blood pressure of 72/34. What is the nurse's next action?

  1. Titrate the drip to 10mcg/kg/min
  2. Stop the drip and call the physician
  3. Start one liter of NS
  4. 1 and 3

Rationale:

Dobutamine is an adrenergic agonist and first-line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts like a chemical balloon pump that reduces afterload but increases the rate and cardiac contractility. It increases cardiac output and mild vasodilation. Dobutamine will cause hypotension in the presence of hypovolemia. Stop infusion and address fluid volume losses if hypotension occurs after infusion.

The same patient responds to the discontinuation of the drip and the infusion of a rapid fluid bolus of 3 L. The urine output has increased to 60 ml/hr. The cardiac monitor indicates a sinus rhythm of 89, oxygen saturation of 96% on a 40% face mask, and blood pressure of 100/58. The physician orders the dobutamine to be restarted at 5 mcg/kg/min, titrate to keep SBP >100. After 30 minutes, the heart rate is 86, the blood pressure is 116/64, and the oxygen saturation is 95%. Which of the following actions should the nurse perform?

  1. Titrate the drip to 7 mcg/kg/min.
  2. Continue to monitor vital signs every five minutes
  3. Start the NS bolus again
  4. Stop the drip and call the physician

Rationale:

Dobutamine is an adrenergic agonist and first-line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. This drug will cause hypotension in the presence of hypovolemia. Stop infusion and address fluid volume losses if hypotension is noted after infusion. The onset is 1-2 minutes, and the half-life is two minutes. Dobutamine is fast-acting, and vital signs are done continuously on the bedside monitor and documented frequently. Each facility has a policy on the frequency of vital sign documentation. Every 5-15 minutes is standard for vital sign documentation with a patient on a vasoactive drip.

Vasopressin

Vasopressin is an antidiuretic hormone. It has unlabeled use in septic shock. It also treats PEA and VF. American Heart Association/Advanced Cardiovascular Life Support (AHA/ACLS) guidelines recommend Vasopressin 40 units once to replace the first or second dose of epinephrine. It requires central line administration but can be administered peripherally until central access is established. Its two primary functions are to retain water in the body and constrict blood vessels, thereby increasing blood pressure, increasing systemic vascular resistance, and decreasing heart rate. The standard concentration is Vasopressin 20 units/100 ml D5W or NS equaling 0.2 units/ml. The drip is initially started at 0.01 units/min (range: 0.01-0.04 units/min). Vasopressin is used in patients with refractory shock despite marked fluid resuscitation and catecholamines such as norepinephrine and dopamine.

It can cause adverse reactions of arrhythmias, cardiac arrest, angina, myocardial ischemia, and peripheral constriction. These reactions are usually seen in doses > 0.04 units/minute. Doses greater than 0.04 units/min may lead to cardiac arrest. Rapid rebound hypotension is a frequent reaction to the abrupt discontinuation of the drip. Ideally, Vasopressin should be titrated down slowly by 0.01 unit/minute increments before discontinuing the drip to avoid adverse reactions.

VASOPRESSIN CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose ordered
units/minute
Vasopressin
20 units/100 ml
Special Instructions
0.01 u/min3 ml/hrMetabolized by kidneys/liver
0.02 u/min6 ml/hrSevere vasoconstriction
0.03 u/min9 ml/hrThe first alternative to epinephrine
0.04 u/min12 ml/hrMonitor for hyponatremia
0.05 u/m15 ml/hrHigh doses can cause ischemia
0.06 u/m18 ml/hr 
0.07 u/m22 ml/hr 

Scenario

A 69 y/o female with a urinary tract infection spikes a temperature of 103 degrees orally. Her heart rate is 120, her blood pressure is 80/56, and her oxygen saturation is 93%. Levofloxacin 750 mg IV is administered, blood cultures are ordered, and 1 liter of NS is administered. She is making about 10 ml of urine an hour. The doctor ordered another L of NS. Her blood pressure is now 74/40. The physician says she needs to go to the ICU for septic shock. Before she is transferred from the ER to the ICU, which of the following should the physician order?

  1. Dopamine
  2. Dobutamine
  3. Vasopressin
  4. Norepinephrine

Rationale:

Vasopressin is an antidiuretic hormone. It has unlabeled use in septic shock. It requires central line administration but can be administered peripherally until central access is established. Its two primary functions are to retain water in the body and to constrict blood vessels.

Which of the following is the antidiuretic hormone used for septic shock?

  1. Levophed
  2. Epinephrine
  3. Cordarone
  4. Vasopressin

Rationale:

Vasopressin is an antidiuretic hormone. It has unlabeled use in septic shock.

A 53 y/o male is in cardiac arrest. He is pulseless, with a waveform of VF on the monitor. He is receiving CPR and has had one automated external defibrillator (AED) shock of 120 joules. VF is still on the monitor. He did not respond to the one dose of IV epinephrine. What is the next drug of choice?

  1. Atropine
  2. Vasopressin
  3. High dose epinephrine
  4. Levophed

Rationale:

Vasopressin is an antidiuretic hormone. It has unlabeled use in septic shock. It also treats PEA and VF. ACLS guidelines no longer recommend Vasopressin to replace the first or second dose of epinephrine (Craig-Brangen & Day, 2021).

Vasodilators

Nipride

Nipride (sodium nitroprusside) is indicated for hypertensive crisis, acute pulmonary edema, and congestive heart failure. It decreases cardiac afterload. Nipride is a potent vasodilator but must be protected from light. It acts quickly and is swiftly reversed. Nipride can produce cyanide toxicity; the signs and symptoms of toxicity may include metabolic acidosis, mental status changes, bradycardia, and seizures (Holme & Sharmin, 2023). To prevent cyanide toxicity, thiocyanate levels must be monitored, usually on or after the third day of therapy. It is mixed 50 mg in 250 ml D5W (200 mcg/ml). The dose is 0.5-4 mcg/kg/min and slowly titrated until the desired blood pressure decrease is achieved; if reaching the 10 mcg/kg/min, do not keep the dose for longer than ten minutes at a time. It cannot be stopped abruptly, which may cause rebound hypertension and seizures, but should be weaned over 10-30 minutes (Ballarat Health Services, 2020).

NIPRIDE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose ordered mcg/kg/min75 kg80 kg90 kg100 kg
0.511 ml/hr12 ml/hr13.6 ml/hr15 ml/hr
122.5 ml/hr24 ml/hr27 ml/hr30 ml/hr
367 ml/hr72 ml/hr81 ml/hr90 ml/hr
5112.5 ml/hr120 ml/hr135 ml/hr150 ml/hr
7157.5 ml/hr168 ml/hr189 ml/hr210 ml/hr
10225 ml/hr240 ml/hr270 ml/hr300 ml/hr

Scenario

A 34 y/o male, 75 kg, with high blood pressure, comes to the ER with a headache. His blood pressure is 220/117. His heart rate is 80, and oxygen saturation is 99% on room air. He denies chest pain, shortness of breath, and fever. He said he is on Lasix but has gained weight. He did not respond to oral clonidine administration. The healthcare provider wants to start a drip to control the blood pressure. Which of the following is the best vasodilator choice for a hypertensive crisis?

  1. Amiodarone
  2. Heparin
  3. Dopamine
  4. Nipride

Rationale:

Nipride (sodium nitroprusside) is indicated for hypertensive crisis, acute pulmonary edema, and congestive heart failure. It decreases cardiac afterload and is a potent vasodilator.

Which drug is cyanide toxic and must have thiocyanate levels monitored?

  1. Phenobarbital
  2. Heparin
  3. Nitroglycerin
  4. Nipride

Rationale:

Nipride is cyanide toxic, and thiocyanate levels must be monitored.

The same patient has been on a Nipride drip at 5 mcg/kg/min for 20 minutes. His blood pressure is now 192/100, his heart rate is 84, and his oxygen saturation is 98%. The physician ordered the Nipride drip to be titrated to keep the diastolic blood pressure < 90 and the heart rate > 60 and < 120. What is the subsequent titration of the Nipride?

  1. 1 mcg/kg/min
  2. 3 mcg/kg/min
  3. 7 mcg/kg/min
  4. 10 mcg/kg/min

Rationale:

The starting dose of Nipride is 0.4-4 mcg/kg/min and slowly titrated until desired effect. It cannot be stopped abruptly, which may cause rebound hypertension and seizures. Doses should be titrated every five minutes until the desired effect is achieved (Khan. 2022). Each facility has its policies and follows the healthcare provider's orders. However, when in doubt, check with the pharmacist and suggest that a consultation with a cardiac specialist or other specialists may be applicable, depending on the circumstances.

Nitroglycerin

Nitroglycerin is a nitrate and a potent vasodilator that dilates coronary arteries and decreases preload. It is classified as an anti-anginal and antihypertensive drug and a vasodilator. It is used in acute angina, hypertensive crisis, pulmonary edema, congestive heart failure, and myocardial infarction. It is the drug of choice for cocaine-induced myocardial infarction. It is always prepared in a glass bottle with vented tubing. It usually comes premixed 50 mg/250 ml D5W, equaling 200 mcg/ml. The standard starting dose is 10-20 mcg/min or 3-6 ml/hr. Caution must be used in the presence of oral nitrates, inferior wall myocardial infarction, and sexual performance-enhancing drugs, as life-threatening hypotension can ensue. It can cause severe bradycardia and hypotension.

NITROGLYCERIN CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
Dose Ordered mcg/minNitroglycerin
50 mg/250 ml D5W  
Special Instructions
51.5 ml/hrUse glass bottle
103 ml/hrUse vented tubing
206 ml/hrCeiling dose of 200 mcg/min
309 ml/hrIt may cause SEVERE hypotension
4012 ml/hrIncreases coronary artery perfusion
5015 ml/hrDecreases preload
6018 ml/hrCauses headache
7021 ml/hrReduces cardiac workload
8024 ml/hrOnset 1-2 min/half-life 1-4 min

Scenario

A 41 y/o male with a history of cocaine use comes in with a complaint of chest pain. His heart rate is 116, and his blood pressure is 166/74. His pulse oximeter reading is 100% on 2 L of oxygen via nasal cannula. His troponin is elevated, and he is positive for cocaine on a drug screen. What is the drug of choice for a cocaine-induced myocardial infarction?

  1. Heparin
  2. Nipride
  3. Lidocaine
  4. Nitroglycerin

Rationale:

Nitroglycerin is a nitrate and a strong vasodilator that dilates coronary arteries and decreases preload. It is classified as an anti-anginal and antihypertensive drug and a vasodilator. It is used in acute angina, hypertensive crisis, pulmonary edema, congestive heart failure, and myocardial infarction. It is the drug of choice for cocaine-induced myocardial infarction.

Nitroglycerin is used for myocardial infarction and angina. In an unstable inferior wall myocardial infarction, the dose is started at 10 mcg/min.

  1. True
  2. False

Rationale:

Nitroglycerin administration is used cautiously in the presence of oral nitrates, inferior wall myocardial infarction, and sexual performance-enhancing drugs, as life-threatening hypotension can ensue.

What are some of the special precautions used when hanging nitroglycerin?

  1. Protect from light and give a bolus before administration
  2. Use a glass bottle and vented tubing
  3. Monitor glucose levels
  4. Monitor bicarbonate levels

Rationale:

Nitroglycerin can adhere to plastic. Nitroglycerin must be hung in a glass bottle with vented tubing.

A 55 y/o male comes to the ER with chest pain and left jaw pain for 20 minutes. His heart rate is 71, blood pressure is 132/68, and oxygen saturation is 99%. He denies the use of oral nitrates. His chest pain is 8/10. His chest pain comes down to 6/10 after three sublingual nitroglycerines. His troponin is severely elevated. His current blood pressure is 156/79. The provider orders nitroglycerin 50 mg/250 ml at 10 mcg/min. How many ml/hr will the pump be set?

  1. 5
  2. 10
  3. 3
  4. 6

Rationale:

Nitroglycerin 50 mg/250 ml is 200 mcg/ml.

1x60 = 0.3 10 mcg/min x 0.3/200 mcg = 3 ml/hr

 
 

Antiarrhythmics

Diltiazem

Diltiazem (Cardizem) is a calcium channel blocker and antiarrhythmic for heart rate control during atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and atrial fibrillation with a rapid ventricular response; it is sometimes used as an antihypertensive. Please do not use it for wide-complex QRS tachycardias. The antidote for diltiazem is calcium. It is mixed as a 1:1 drip. It is mixed with 125 mg/100 ml NS. The 125 mg of diltiazem is 25 ml volume, making the drip 125 mg/125 ml. For acute rate control, an initial bolus of 5-20 mg (0.25 mg/kg over two minutes; if inadequate response, 0.35 mg/kg over two minutes) IV push is usually administered to evaluate the response and blood pressure tolerance. The drip is then started at 5 mg/hr (5 ml/hr) and titrated up by 2-5 mg every 15-30 minutes for effect to a maximum dose of 15 mg/hr (15 ml/hr). Titration is done until a physiologically appropriate heart rate is reached. Caution is to be used in patients with 1st-degree atrioventricular block (AVB), Wolff-Parkinson-White (WPW) syndrome, VT, sick sinus syndrome, and short PR syndrome. Blood pressure must be monitored every five minutes during titration as diltiazem can rapidly decrease blood pressure. Start low and go slow with diltiazem; most patients respond well to the 5 mg IV push.

DILTIAZEM CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
The dose ordered mg/hrDiltiazem
125 mg /100 ml NS
Special Instructions
55 ml/hrIt can cause severe hypotension
1010 ml/hrCan cause hypocalcemia
1515 ml/hrCalcium is antidote
2020 ml/hrMonitor blood pressure continuously
2525 ml/hrMonitor QRS for widening

Scenario

Atrial fibrillation with rapid ventricular response at a rate of 188 will need to be treated with an antiarrhythmic. Which antiarrhythmic is the best choice for this patient?

  1. Amiodarone
  2. Lidocaine
  3. Esmolol
  4. Diltiazem

Rationale:

Diltiazem (Cardizem) is a calcium channel blocker and antiarrhythmic for heart rate control during atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and atrial fibrillation with a rapid ventricular response.

The drug of choice for atrial fibrillation is diltiazem. It is a calcium channel blocker. Which of the following is the usual initial loading dose?

  1. 0.25 mg/kg over two minutes
  2. 0.40 mg/kg over two minutes
  3. 10 mg
  4. 20 mg

Rationale:

An initial bolus of diltiazem for atrial fibrillation for acute rate control of 5-20 mg (0.25 mg/kg over two minutes; if there is inadequate response, 0.35 mg/kg over two minutes) IV push is usually administered to evaluate the response and blood pressure tolerance.

Diltiazem is an antiarrhythmic used for rate control in atrial fibrillation. Its mechanism of action is slowing calcium in vascular and cardiac muscle tissue. What is the antidote for diltiazem?

  1. Epinephrine
  2. Benadryl
  3. Calcium
  4. Steroids

Rationale:

Diltiazem (Cardizem) is a calcium channel blocker and antiarrhythmic for heart rate control during atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and atrial fibrillation with a rapid ventricular response. Please do not use it for wide-complex QRS tachycardias. The antidote for diltiazem is calcium.

A 44 y/o male with atrial fibrillation and rapid ventricular rate (RVR) with a heart rate of 156 is being given 10 mg of diltiazem IV bolus. The patient's heart rate responds to the calcium channel blocker, and the heart rate is now 90. The physician orders a diltiazem drip to be started. 125 mg (25 ml) of diltiazem is mixed with 125 ml of NS. The 1:1 drip is ordered to infuse at 5 mg/hr with parameters to keep the SBP > 100 and the heart rate < 110 but > 50. The drip has been infusing for 15 minutes. The patient's vital signs are a heart rate of 133 and a blood pressure of 134/80. How is the drip titrated?

  1. Stop the drip
  2. Call the physician and stop the drip
  3. Increase the drip to 10 mg/hr
  4. Decrease the drip to 2 mg/hr

Rationale:

For acute rate control, an initial bolus of 5-20 mg (0.25 mg/kg over two minutes; if inadequate response, 0.35 mg/kg over two minutes) IV push is usually administered to evaluate the response and blood pressure tolerance. The drip is then started at 5 mg/hr (5 ml/hr) and titrated up by 2-5 mg every 15-30 minutes for effect to a maximum dose of 15 mg/hr (15 ml/hr).

Amiodarone

Amiodarone is for the management of life-threatening recurrent VF or hemodynamically unstable VT and cardiac arrest. It is commonly used for VF pulseless and VT unresponsive to shock delivery and cardiopulmonary resuscitation (CPR). It is an antiarrhythmic. The dosing is standard for all patients with a 150 mg/100 ml D5W (1.5 mg/ml) bolus over ten minutes. The bolus may be repeated if needed. A 300 mg bolus, diluted in 100 ml D5W over ten minutes, may also be used for VF, VT, and cardiac arrest unresponsive to CPR. The drip is mixed 450 mg/250 ml D5W and runs at 1 mg/min (33 ml/hr) for six hours, then 0.5 mg/min (16 ml/hr) for 18 hours with a transition to oral Cordarone after the drip is discontinued. It has a 53-day half-life. It can cause hypotension, bradycardia, proarrhythmic events, peripheral neuropathy, thyroid dysfunction, thyroid storm, nausea, vomiting, and pulmonary toxicity. Do not administer to pregnant/lactating patients. Administer through a central venous catheter with an in-line filter. Amiodarone is associated with a high incidence of extravasation.

AMIODARONE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
The dose ordered after a bolus of 150 mg or 300 mgAmiodarone
1.8 mg/ml
450 mg/250 ml D5W
Maintenance InfusionSpecial Instructions
1 mg/minute33 ml/hr for 6 hrs360 mg over 6 hrsMonitor blood pressure
0.5 mg/min16 ml/hr for 18 hrs540 mg over 18 hrsMonitor QT interval

Scenario

A 65 y/o male presents to the ER via ambulance with VF. The ambulance crew started an IV and NS. The patient has an automatic implantable cardioverter defibrillator (AICD) in place, but it is not functional. The healthcare provider wants to start an antiarrhythmic. Which medication is the best choice?

  1. Norepinephrine
  2. Lidocaine
  3. Dopamine
  4. Amiodarone

Rationale:

Amiodarone is for the management of life-threatening recurrent VF or hemodynamically unstable VT and cardiac arrest. It is commonly used for VF pulseless and VT unresponsive to shock delivery and CPR. It is an antiarrhythmic.

The initial bolus dose of amiodarone for life-threatening VF or unstable VT is 20 mg IV push.

  1. True
  2. False

Rationale:

The dosing is standard for all patients with a 150 mg/100 ml D5W (1.5 mg/ml) bolus over ten minutes. The bolus may be repeated if needed. A 300 mg bolus, diluted in 100 ml D5W over 10 minutes, may also be used for VF, VT, and cardiac arrest unresponsive to CPR.

A continuous drip infusion follows an amiodarone 300 mg bolus. The amiodarone drip will infuse for _______hours before transitioning to oral Cordarone.

  1. 72
  2. 48
  3. 24
  4. 36

Rationale:

A 300 mg bolus, diluted in 100 ml D5W over ten minutes, may also be used for VF, VT, and cardiac arrest unresponsive to CPR. The drip is mixed 450 mg/250 ml D5W and runs at 1 mg/min (33 ml/hr) for six hours, then 0.5 mg/min (16 ml/hr) for 18 hours with a transition to oral Cordarone after the drip is discontinued. The total time is 24 hours.

Many vasoactive medications have serious side effects. Which medication puts the patient at risk for a thyroid storm?

  1. Nipride
  2. Diltiazem
  3. Amiodarone
  4. Adenosine

Rationale:

It has a 53-day half-life. It can cause hypotension, bradycardia, ectopy and arrhythmic events, peripheral neuropathy, thyroid dysfunction, thyroid storm, nausea, vomiting, and pulmonary toxicity.

A patient on an amiodarone drip exhibits signs and symptoms of thyroid dysfunction. The amiodarone drip is discontinued. The patient's vital signs are stable. The first dose of Cordarone is due in 12 hours. Which of the following should the nurse do?

  1. Administer Cordarone as scheduled.
  2. Monitor the heart rate.
  3. Restart the drip.
  4. Do not administer Cordarone.

Rationale:

Cordarone is amiodarone and may cause a thyroid storm. The amiodarone infusion has a long half-life of 53 days. Another antiarrhythmic should be ordered.

Rationale:

Use caution in older adults, as a complete heart block can occur. It can also cause confusion, hypotension, lightheadedness, diplopia, seizures, and tinnitus.

Lidocaine

Lidocaine (Xylocaine) is a ventricular antiarrhythmic medication. It is usually premixed but should be 2 grams (G)/500 ml D5W, 4 mg/ml. A 1-1.5 mg/kg IV bolus over 2-3 minutes is initiated for ventricular arrhythmias. The dose may be repeated for a total of 2 mg/kg. This action is followed by the initial drip start-up at 1-4 mg/minute. It suppresses ventricular arrhythmias by decreasing automaticity. The onset is 30-90 seconds. Use caution in older adults, as a complete heart block can occur. It can also cause confusion, hypotension, lightheadedness, diplopia, seizures, tinnitus, and perioral numbness, all of which may be a sign/symptom of toxicity. It is contraindicated in a complete or 2nd degree AVB, and the dose needs to be decreased for those patients with congestive heart failure or hepatic disease (Mrad et al., 2019). Although the drug is still considered a drug for ACLS protocols, it remains to be seen if it is superior to amiodarone; Achilli (2023) reports that the drug is superior to amiodarone, while Wang et al. (2023) cites amiodarone as slightly better in clinical outcomes.

LIDOCAINE CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy)
The dose ordered
mg/min
Lidocaine
2 G/500 ml
Special Instructions
115 ml/hrMonitor for bradycardia
230 ml/hrDo not use in acute myocardial infarction
345 ml/hrMonitor for heart block
460 ml/hrWatch for circulatory depression

Scenario

A 65 y/o female patient is on lidocaine 2 mg/min for VT of 160. The bedside alarm indicates a change in heart rate to 49. The patient is lethargic but arousable to noxious stimuli. Her oxygen saturation is 95%. Her blood pressure is 106/58. What is the next action?

  1. Start dopamine
  2. Hang NS
  3. Stop Lidocaine
  4. Retake vital signs

Rationale:

Lidocaine (Xylocaine) is a ventricular antiarrhythmic medication. It is usually premixed but should be 2 G/500 ml D5W, 4 mg/ml. For ventricular arrhythmias, a 1-1.5 mg/kg IV bolus over 2-3 minutes is initiated. The dose may be repeated for a total of 2 mg/kg. This action is followed by the initial drip start-up at 1-4 mg/minute. It suppresses ventricular arrhythmias by decreasing automaticity.

Esmolol

Esmolol (Brevibloc) is indicated for sinus tachycardia to control heart rate and ventricular response, supraventricular tachycardia (SVT), and hypertension. It is a selective beta-blocking agent and antiarrhythmic. Esmolol will quickly decrease heart and cardiac output and systemic vascular resistance, decreasing cardiac oxygen demand. It is imperative that dosing is accurate as the drug acts rapidly. The half-life is nine minutes. The drug may or may not be given as a bolus due to its quick onset. If a bolus is desired, 250-500 mcg/kg undiluted may be given IV push over one minute. Mix 2.5 grams of esmolol in 250 ml D5W, equaling 10 mg/ml. The drip may be started at 50 mcg/kg/min and titrated up to 300 mcg/kg/min every five minutes to control heart rate, cautiously monitoring blood pressure during titration. Do not stop the medication abruptly.

ESMOLOL CHART (verify all doses, concentrations, and titration policies with physician and facility pharmacy) Esmolol 2.5 G/250 ml D5W = 10 mg/ml
Dose ordered mcg/kg/min75 kg
ml/hr
80 kg
ml/hr
85 kg
ml/hr
90 kg
ml/hr
95 kg
ml/hr
5022.5 ml/hr24 ml/hr25.5 ml/hr27 ml/hr28.5 ml/hr
7534 ml/hr36 ml/hr38 ml/hr41 ml/hr43 ml/hr
10045 ml/hr48 ml/hr51 ml/hr54 ml/hr57 ml/hr
15067.5 ml/hr72 ml/hr76.5 ml/hr81 ml/hr85.5 ml/hr
20090 ml/hr96 ml/hr102 ml/hr108 ml/hr114 ml/hr
250112.5 ml/hr120 ml/hr127.5 ml/hr135 ml/hr142.5 ml/hr
300135 ml/hr144 ml/hr153 ml/hr162 ml/hr171 ml/hr

Scenario

Which medication is used for sinus tachycardias, especially ventricular rates?

  1. Lidocaine
  2. Nitroglycerin
  3. Dopamine
  4. Esmolol

Rationale:

Esmolol (Brevibloc) is indicated for sinus tachycardia, heart rate and ventricular response control, SVT, and hypertension. It is a selective beta-blocking agent and antiarrhythmic.

A 34 y/o female presents to the ER with an SVT of 199. She is 36 weeks pregnant. Her blood pressure is 149/77. She is in no pain and is not in labor. Her oxygen saturation is 96% on two liters via nasal cannula. IV access is established, and an ECG is completed. The doctor wants to start an antiarrhythmic. What is the best choice for this patient?

  1. Amiodarone
  2. Esmolol
  3. Atropine
  4. Nitroglycerin

Rationale:

Amiodarone is contraindicated in pregnant and lactating patients. Atropine and nitroglycerin are not antiarrhythmic medications.

A 61 y/o female is on an esmolol drip at 70 mcg/kg/min for SVT. She has been on the drip for 36 hours. The orders for the drip are to keep the heart rate < 110 and > 60 and to keep the SBP < 160 and > 90. She has no known allergies, and her weight is 90 kg. Her vital signs have been within parameters for 12 hours. However, her vital signs have changed; her heart rate is 146, and her blood pressure is 150/90. The next action of the nurse is:

  1. Titrate the drip to 75 mcg/kg/min
  2. Titrate the drip to 65 mcg/kg/min
  3. Stop the drip and call the physician
  4. Continue vital signs every five minutes

Rationale:

Esmolol (Brevibloc) is indicated for sinus tachycardia, heart rate control and ventricular response, SVT, and hypertension. It is imperative that dosing is accurate as the drug acts rapidly. Half-life is nine minutes. The drip may be started at 50 mcg/kg/min and titrated up to 300 mcg/kg/min every five minutes to control heart rate, cautiously monitoring blood pressure during titration. Do not stop the medication abruptly.

The same patient has a heart rate of 101 and a blood pressure of 128/60. Her glucose is 76. Her urine output is 60 ml/hr. The esmolol remains at 75 mcg/kg/min. What is the nurse's next action?

  1. Increase drip to 80 mcg/kg/min
  2. Call the physician
  3. Continue to monitor vital signs every five minutes
  4. Start a NS fluid bolus

Rationale:

The vital signs are within the parameters of the esmolol order.

Twenty-four hours later, the same patient remains in the ICU. The esmolol drip is 75 mcg/kg/min. The heart rate is 60, and the blood pressure is 90/62. The oxygen saturation is 98. She is alert and oriented. The urine output is 60 ml/hr. She is in no distress. Which of the following is the nurse's next action?

  1. Stop the drip
  2. Call the physician
  3. Increase the drip
  4. Document vital signs every 60 minutes.

Rationale:

The drip cannot be stopped abruptly. The patient has vital signs on the lowest end of the parameters, so titration is not indicated per the order. The vital signs are continuous. The physician needs to be called to determine if the parameters for the vital signs and the drip titration should be changed.

Adenosine

Adenosine is used to treat paroxysmal SVT (PSVT) and WPW syndrome; this type of arrhythmia can be severe. It is an antiarrhythmic. Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10 ml NS flush is administered immediately after the IV push for PSVT. If not effective within 1-2 minutes, 12 mg may be given again; a third 12 mg bolus if needed for persistent SVT; maximum single dose: 12 mg. Adenosine is a powerful vasodilator in most vascular beds. Adenosine is thought to work through the activation of purine receptors. Evidence supports both inhibitions of the slow inward calcium current, reducing calcium uptake and activating adenylate cyclase. Adenosine modulates sympathetic neurotransmission, lessening vascular tone. Adenosine blocks faulty circuitry in the heart, which causes an irregular heart rhythm. Adenosine slows conduction time through the atrioventricular (AV) node and interrupts the reentry pathways through the AV node. A transient episode of asystole will occur after the administration of adenosine; this is usually self-limited, secondary to the extremely short half-life of the drug. The patient usually returns to their normal underlying rhythm after the administration of adenosine. Patients frequently complain of chest pain and shortness of breath after the administration of this drug. This medication is never given as a continuous infusion.

Scenario

A 16 y/o female with WPW is brought to the ER by her mom with a complaint of, "Her heart rate is high again." The cardiac monitor shows a heart rate of 220 and a blood pressure of 92/44. Which medication will the doctor order for rate control?

  1. Adenosine
  2. Lidocaine
  3. Nitroglycerin
  4. Diltiazem

Rationale:

Adenosine is used to treat PSVT and WPW syndrome; this type of arrhythmia is deadly. It is an antiarrhythmic.

What is the amount of the first dose of adenosine?

  1. 12 mg
  2. 18 mg
  3. 6 mg
  4. 28 mg

Rationale:

Adenosine is used to treat PSVT and WPW syndrome; this type of arrhythmia is deadly. It is an antiarrhythmic. Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10 ml NS flush is administered immediately after the IV push for PSVT. If not effective within 1-2 minutes, 12 mg may be given again; a third 12 mg bolus if needed for persistent SVT; maximum single dose: 12 mg.

A 16 y/o female with WPW is in the ER. Her heart rate is 275, and her blood pressure is 112/62. The physician wants to order another dose of adenosine. Which is the next dose for this patient?

  1. Lidocaine 12 mg
  2. Diltiazem 12 mg
  3. Adenosine 12 mg
  4. Amiodarone 12mg

Rationale:

Adenosine is used to treat PSVT and WPW syndrome; this type of arrhythmia is deadly. It is an antiarrhythmic. It is administered in three bolus doses, only 6 mg, then 12 mg, and finally 12 mg per the ACLS dosing recommendations.

The 16 y/o female with WPW now has a heart rate of 110. Her blood pressure is 120/74. She is admitted to the ICU for monitoring of her PSVT. After successfully correcting the WPW with the adenosine bolus, the healthcare provider orders an adenosine drip. What will the infusion rate be in ml/hr?

  1. 6 mg
  2. 12 mg
  3. 18 mg
  4. No drip indicated

Rationale:

Adenosine is never given as a continuous infusion.

How To Use the Drug Calculation Formula

Ordered amount of drug x patients' weight in kg x 60 minutes/Drug concentration (mg divided by ml) then multiply x 1000 for mcg
= ml/hr

EXAMPLE: A physician orders dopamine 5 mcg/kg/min. titrate to keep SBP > 100 and MAP > 65.

The hospital pharmacy has premixed Dopamine 400 mg/250 ml D5W. Your patient weighs 75 kg.

5x75x60/400/250 x 1000 (1.6 mg/ml or 1600 mcg/ml)
= 14.06 ml/hr

Here is an explanation of each element:

  • 5 is the order of Dopamine (5mcg)
  • 75 kg is the patient weight
  • 60 minutes (# of minutes in an hour)
  • 400 mg of dopamine in 250 ml D5W (change mg to mcg/1 mg=1000 mcg)

EXAMPLE: A physician orders Epinephrine 2 mcg/min, titrate for SBP > 100 and heart rate > 80 and heart rate < 110.

This medication is mixed at the bedside. Epinephrine 1 mg is added to 250 ml D5W.

2x60/1/250x1000 (4 mcg/ml)
= 30 ml/hr

Here is an explanation of each element:

  • 2 mcg is the order of the epinephrine
  • The kg # is omitted as the medication is NOT weight-based
  • 60 minutes (# of minutes in an hour)
  • 1 mg of epinephrine in 250 ml D5W (change to mcg, 1 mg=1000 mcg)

EXAMPLE: Physician orders Lidocaine 2 mg/min, titrate for ventricular ectopy, maintaining heart rate > 60 and SBP > 90

The hospital has premixed Lidocaine 2 G/500 ml D5W.

2x60/2/500x1000 (2 G must be converted to mg) 
= 30 ml/hr

Here is an explanation of each element:

  • 2 mg is the order for the lidocaine
  • The kg # is omitted as the medication is NOT weight-based
  • 60 minutes (# of minutes in an hour)
  • 2 G of lidocaine in 500 ml D5W (change G to mg/ 1 G=1000 mg)

The drug calculation formula will work for all vasoactive drips using only the elements needed for the ordered drip infusion.

Vasoactive Medications for the Pediatric Patient

The use of vasoactive medications in the pediatric population are commonly used in cases of sepsis and septic shock, cardiac arrest, management of blood pressure following brain surgery, and pediatric hypertension. The other reasons besides septic shock, as cited by Lasa and Moffett (2018), include all states of shock, including distributive, cardiogenic hypovolemic, and the subtypes of cardiogenic shock related to various heart failure states. According to the New England Journal of Medicine (2023), the use of vasoactive medications is justified in the case of septic shock if IV fluid management is not sufficient or tolerated by the patient. In looking at the use of vasoactive agents in cases of sepsis and septic shock, the first line agents to use may be epinephrine or norepinephrine as dopamine is no longer recommended as a primary agent, a sentiment echoed by Kohn-Loncarica et al. (2020). The deciding factor in which agent to use is based on whether the patient is in warm shock or cold shock; warm shock is characterized by a low cardiac output and a high systemic vascular resistance, whereas a cold shock is the opposite, with a high cardiac output and a low vascular resistance.

The vasoactive medications used most in their pediatric intensive care unit are epinephrine, norepinephrine, dopamine, and vasopressin (Rizza et al., 2016). These agents are measured in mcg/kg/min for all drips except vasopressin, which is given in milliunits. This is a significant change from the adult dosing regarding epinephrine and vasopressin, as vasopressin is measured in units, and epinephrine is dosed in mcg/min for adults.

The two significant precautions for utilizing vasopressors in pediatrics are the risk of extravasation and limb ischemia, which are also risks for adults. Still, the pediatric population needs to be even more vigilant of the risks and the need for frequent monitoring to prevent these outcomes. However, newer studies comparing extravasation rates in diluted vasoactive inotropes in less affluent countries reveal that the extravasation rate is at 3%, which is still a concern but less than once believed.

In looking at how vasoactive medications are given to the pediatric patient, the routes used can be peripheral, central venous access, and intraosseous as this method of delivery of fluids and medications is safe, however, an underutilized delivery method per Hoskins et al. (2022).

The use of vasoactive medications is also used in the neonate for septic shock and can include norepinephrine, dopamine, and Dobutamine. According to Lu et al. (2023), the use of norepinephrine was shown in some instances to be more beneficial to preterm neonates with septic shock than dopamine.

Conclusion

Remember that all vasoactive medications are dose-dependent and need to be administered cautiously. All patients on vasoactive drips need continuous ECG, blood pressure, and oxygen saturation monitoring. All critical care and emergency drips must be administered on an infusion pump. Elderly patients and patients with multiple co-morbidities respond differently and must be monitored constantly. All vasoactive drips should be administered via central access. Peripheral or intraosseous access may be used until central access is obtained; however, all vasoactive drips cause severe tissue injury if extravasation occurs (Castano, 2012). An arterial line is preferred for constant blood pressure monitoring. It is imperative to remember that all medications for blood pressure must be administered while considering fluid volume loss and the need for fluid resuscitation. While many vasoactive drugs can be of great value to the patient, they can also cause life-threatening arrhythmias. Cardiac monitoring is essential while administering these medications and having emergency resuscitative equipment ready in case of medical emergency.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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