Vasoactive Drips: A guide to starting and titrating critical care drips, Adult and Pediatric

Here is the basic equation for formulating, mixing, and calculating drip rates. For this exercise, a consistent patient weight of 75 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 mcg/min, then omit the kg element (JBF, 2015).

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

Levophed (Norepinephrine) is a potent alpha/beta-agonist causing vasoconstriction and increased blood pressure. It is used for severe hypotension, shock, or bradycardia. Mix 4mg levophed in 250ml of D5W, making the drip 16mcg/ml. The standard effective dose is 2-12 micrograms/min. This drug 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 60-65mmHg or SBP >90. Vital signs are monitored continuously and documented every 5 minutes during titration.

Scenario:

A 54 y/o male presents to the ER complaining of feeling weak and dizzy. He has a history of gout, diabetes, GERD, and psoriasis. He is allergic to sulfa. His glucose is 96. He is pale, clammy, and lethargic. His vital signs are heart rate of 101, blood pressure 78/50, oxygen saturation 94%, temperature 97.8, and respirations of 24. A 16g peripheral IV is established, ECG is completed (sinus tachycardia), and oxygen therapy 3L Nasal Cannula (NC) is started. After 3 liters of normal saline, 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 Sulfite 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 min, the patient vital signs are heart rate of 106, B/P 88/42, and saturation of 96%. What is the next 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 the blood pressure rapidly. Monitor the vital signs every 5 minutes and increase the drip again after 20 minutes if necessary to meet the parameters.

Epinephrine is used for profound refractory hypotension, ventricular fibrillation, 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 1mg epinephrine in 250ml 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. This drug can cause hyperglycemia, so glucose levels should be monitored. It can also cause decreased urine output and metabolic acidosis.

Scenario:

A 70 y/o male presents to 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 100% oxygen 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, ventricular fibrillation, VT, PEA, and asystole. It is the first drug of choice for cardiac arrest.

The patient is transferred to the 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 1mg in 250ml of D5W. What is the rate of the infusion in ml/hr?

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

Rationale:

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

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

• 2 mcg is the order of the Epinephrine
• The kg # is omitted as the medication is NOT weight-based

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

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

Rationale:

This drug can cause hyperglycemia, so glucose levels should be monitored. It can also cause HTN and arrhythmias.

Epinephrine is the first drug of choice for cardiac arrest. It is a vasopressor and will increase coronary perfusion. This drug is started at 10 mcg/min and is rapidly titrated up for effect to 20mcg/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 hemodynamic stability. However, more is not better. High doses do not improve outcomes and can cause post-resuscitation myocardial dysfunction.

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. If the etiology of the shock is unknown, then dopamine is a good first-line drug of choice. It is a positive inotrope with vasoconstrictive actions. It tends to exhibit beta-agonist in low doses. In higher doses, it acts more like an alpha agonist. It will increase cardiac output and heart rate. It will augment cardiac performance and renal perfusion in shock and sepsis.

Dopamine is mixed 400 mg in 250 mL/D5W equaling 1600 mcg/ml. The onset of action is 5 minutes, and the half-life is 2 minutes. The dose is 2-20 mcg/kg/min. it is usually started at 5mcg/kg/min. This drug is contraindicated in patients with sulfite 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.

Scenario:

A 54 y/o female in the ICU starts to have a decrease in blood pressure and urine output. Her B/P is 88/40, and her urine output is less than 30ml/hr. She has received 2 liters 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 5mcg/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 400mg in 250ml D5W. What will the infusion rate be in ml/hr?

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

Rationale:

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

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

Here is an explanation of each element:

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

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 40mcg/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 400 mg in 250cc/D5W equaling 1600mcg/ml. The onset of action is 5 minutes, and the half-life is 2 minutes. The dose is 2-20mcg/kg/min. it is usually started at 5mcg/kg/min.

The best adrenergic agonist for central hypotension, heart failure, and increased renal perfusion is:

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 30ml/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. 45 minutes later, the patient has a heart rate of 110, and blood pressure is 90/58. What is the next action of the nurse?

1. Titrate the drip up to 15mcg/kg/min
2. Call the physician
3. Keep the drip at 10mcg/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 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. This drug will cause hypotension in the presence of hypovolemia. If hypotension is noted after infusion, stop the infusion, and address fluid volume losses. This drug can cause tachycardia and headache. It is contraindicated in patients with sulfite allergy Onset is 1-2 minutes, and the half-life is 2 minutes.

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

Scenario:

A 77y/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, blood pressure is 72/44, and 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-reduces afterload but increases the rate and cardiac contractility.

After 3 liters of fluid, the same patient remains hypotensive with a blood pressure of 88/42, and a MAP <60. His urine output is 30ml/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 5mcg/kg/min. Mix 500 mg in 250 ml D5W for 2000 mcg/ml. The infusion pump is set at 7ml/hr. The bedside cardiac monitor, two minutes after the infusion is started, shows a heart rate of 126, saturation 90%, and blood pressure of 72/34. The next action of the nurse is?

1. Titrate the drip to 10mcg/kg/min
2. Stop the drip and call the physician
3. Start one liter of normal saline
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. This drug will cause hypotension in the presence of hypovolemia. If hypotension is noted after infusion, stop infusion, and address fluid volume losses.

The same patient responds to the discontinuation of the drip and the infusion of a rapid fluid bolus of 3 liters. 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 5mcg/kg/min, titrate to keep SBP>100. After 30 minutes, the heart rate is 86; the blood pressure is 116/64; oxygen saturation is 95%. What is the next action of the nurse?

1. Titrate the drip to 7 mcg/kg/min
2. Continue to monitor vital signs every 5 minutes
3. Start the normal saline 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. If hypotension is noted after infusion, stop infusion, and address fluid volume losses. Onset is 1-2 minutes, and the half-life is 2 minutes. This drug 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 is an antidiuretic hormone. It has unlabeled use in septic shock. It also treats PEA and VF. AHA/ACLS guidelines recommend Vasopressin 40 units one time only 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. It 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.

Scenario:

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

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.

The antidiuretic hormone used for septic shock is:

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 ventricular fibrillation on the monitor. He is receiving CPR and has had one AED shock of 120 joules. VF is still on the monitor. He did not respond to the 1 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 recommend vasopressin to replace the first or second dose of Epinephrine (Craig-Brangen et al., 2019).

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. 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 125 mg/100 mL NS. The 125mg of Diltiazem is 25ml volume making the drip 125mg/125ml. An initial bolus, for acute rate control, of 5mg-20mg (0.25 mg/kg over 2 min; if inadequate response, 0.35 mg/kg over 2 minutes) intravenous push is usually administered to evaluate the response and blood pressure tolerance. The drip is then started at 5 mg/hr (5ml/hr) and titrated up by 2-5mg every 15-30 minutes for effect to a maximum dose of 15 mg/hr (15ml/hr). Titration is done until a physiologically appropriate heart rate is reached. Caution is to be used in patients with; 1st-degree AVB, WPW syndrome, ventricular tachycardia, SSS, and short PR syndrome. Blood pressure must be monitored every five minutes as Diltiazem can rapidly decrease blood pressure. Start low and go slow with Diltiazem; most patients respond well to 5mg IV push.

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. The usual initial loading dose is?

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

Rationale:

An initial bolus of Diltiazem for atrial fibrillation for acute rate control of 5mg-20mg (0.25 mg/kg over 2 min; if inadequate response, 0.35 mg/kg over 2 minutes) intravenous 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. Do not use it for wide complex QRS tachycardias. The antidote for Diltiazem is calcium.

A 44 y/o male with atrial fibrillation and RVR with a heart rate of 156 is being given 10mg of diltiazem IV bolus. The patient heart rate responds to the calcium channel blocker, and the heart rate is now 90. The physician orders a diltiazem drip to be started. 125mg (25ml) of Diltiazem is mixed with 125 ml of normal saline. The 1:1 drip is ordered to infuse at 5mg/hr with parameters to keep the SBP greater than 100 and the heart rate less than 110 but greater than 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 10mg/hr
4. Decrease the drip to 2mg/hr

Rationale:

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

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 dosing is standard for all patients with a bolus of 150 mg/100 mL D5W (1.5 mg/ml) over 10 minutes. The bolus may be repeated if needed. A 300 mg bolus, diluted in 100ml D5W over 10 minutes, may also be used for VF, VT, and cardiac arrest unresponsive to CPR. The drip is mixed 450mg/250 mL D5W and runs at 1mg/min (33 mL/hr.) for 6 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.

Scenario:

A 65 y/o male presents to the ER via ambulance with ventricular fibrillation. The ambulance crew started an IV and Normal Saline. The patient has an AICD in place, but it is not functional. The doctor 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 20mg IVP.

1. True
2. False

Rationale:

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

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

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

Rationale:

A 300mg bolus, diluted in 100ml D5W over 10 minutes, may also be used for VF, VT, and cardiac arrest unresponsive to CPR. The drip is mixed 450mg/250 mL D5W and runs at 1mg/min (33 mL/hr.) for 6 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. What is the next action for the nurse?

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

Rationale:

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

Rationale:

Use caution in the elderly as a completed heart block can occur. It can also cause confusion, hypotension, lightheadedness, diplopia, seizures, and tinnitus.

Lidocaine (Xylocaine) is a ventricular antiarrhythmic medication. It is usually premixed but should be 2grams/500ml D5W, 4mg/ml. A 1-1.5mg/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 arrhythmia by decreasing automaticity. The onset is 30-90 seconds. Use caution in the elderly 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 AV block, and the dose needs to be decreased for those patients with congestive heart failure or hepatic disease (Mrad et al., 2019). The drug is still considered a primary medication for use in ACLS and is given equal consideration with Amiodarone per Craig-Brangen and Day (Craig-Brangen et al., 2019).

Scenario:

A 65 y/o female patient is on lidocaine 2mg/min for ventricular tachycardia 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 normal saline
3. Stop Lidocaine
4. Retake vital signs

Rationale:

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

Esmolol (Brevibloc) is indicated for sinus tachycardia to control heart rate and ventricular response, supraventricular tachycardia, and hypertension. It is a selective beta-blocking agent and antiarrhythmic. Esmolol will decrease heart, cardiac output, and SVR, decreasing cardiac oxygen demand. It is imperative that dosing is accurate as the drug acts rapidly. The half-life is 9 minutes. The drug may or may not be given as a bolus due to its quick onset. If a bolus is desired, 250-500mcg/kg undiluted may give IV push over one minute. Mix 2.5grams Esmolol in 250ml D5W equaling 10mg/ml. The drip may be started at 50mcg/kg/min and titrate up to 300mcg/kg/min every 5 minutes to effect heart rate control, cautiously monitoring blood pressure during titration. Do not stop the medication abruptly.

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, control heart and ventricular response, supraventricular tachycardia, 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 2 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 70mcg/kg/min for SVT. She has been on the drip for 36 hours. The orders for the drip are to keep the heart rate less than 110, and greater than 60, and to keep SBP<160 and >90. She has NKA, and her weight is 90kg. Her vital signs have been within parameters for 12 hours. However, her vital signs change, and her heart is now 146, and her blood pressure is 150/90. The next action of the nurse is?

1. Titrate the drip to 75mcg/kg/min
2. Titrate the drip to 65mcg/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, supraventricular tachycardia, and hypertension. It is imperative that dosing is accurate as the drug acts rapidly. The half-life is 9 minutes. The drip may be started at 50mcg/kg/min and titrate up to 300mcg/kg/min every 5 minutes to effect heart rate control, 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 60ml/hr. The Esmolol remains at 75mcg/kg/min. What is the next action of the nurse?

1. Increase drip to 80mcg/kg/min
2. Call the physician
3. Continue to monitor vital sign every 5 minutes
4. Start a normal saline fluid bolus

Rationale:

The vital signs are within parameters of the Esmolol order.

Twenty-four hours later, the same patient remains in the ICU. The Esmolol drip is at 75mcg/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 60ml/hr. She is in no distress. The next action of the nurse is?

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 and determine if the parameters should be changed for the vital signs and the drip titration.

Adenosine is used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. It is an antiarrhythmic. Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10ml normal saline flush immediately after the intravenous push is administered 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 an extremely strong 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 activation of adenylate cyclase. Adenosine modulates sympathetic neurotransmission lessening vascular tone — adenosine blocks faulty circuitry in the heart, which causes irregular heart rhythm. Adenosine slows conduction time through the A-V node and interrupts the reentry pathways through the A-V 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 Adenosine. 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 Adenosine. 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 336 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 paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. It is an antiarrhythmic.

What is the amount of the first dose of Adenosine?

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

Rationale:

Adenosine is used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. It is an antiarrhythmic. Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10ml normal saline flush immediately after the intravenous push is administered 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 paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. It is an antiarrhythmic. It is administered in 3 doses of bolus, only 6mg, then 12mg, then finally 12 mg per the ACLS dosing recommendations.

The 20 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 paroxysmal supraventricular tachycardia. The physician orders an adenosine drip after successfully correcting the WPW with the adenosine bolus. What will be the infusion rate in ml/hr?

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

Rationale:

This medication is never given as a continuous infusion.