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

3 Contact Hours including 3 Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Thursday, March 3, 2022
Outcomes

Participants will be able to provide a guideline for ordering, dosing, and titrating cardiovascular and critical care medications in the critical care unit.

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, inotropes, catecholamine, and adrenergic.
  4. Identify vasoactive drugs, infusion rates, and other medications used to treat critically ill patients.
  5. Describe how to calculate and verify drug mixtures every time a critical drug is administered.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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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 a vasoactive drug infusion for therapeutic effect.
  • Vasopressor: a class of drugs that induce arteriole vasoconstriction and thereby elevate blood pressure.
  • 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).
  • 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 a positive chronotrope.
  • Catecholamine: any of a class of aromatic amines that includes several neurotransmitters which cause sympathomimetic action (epinephrine, norepinephrine, Dopamine, Dobutamine).
  • Adrenergic: having characteristics of secreting epinephrine or substances with similar activity (epinephrine and norepinephrine).

It should be noted that medications can be classified in multiple classes as chronotropic and/or inotropic.

Introduction

Vasoactive medications are indicated when the Systolic Blood Pressure (SBP) has a decrease of > 30mmHg from the baseline or a Mean Arteriole Pressure (MAP) less than 60-65mmHg and when either condition results in end-organ dysfunction due to hypoperfusion. Additionally, vasoactive medications are used for the management of a hypertensive crisis, flash pulmonary edema, sepsis, shock states, atrial fibrillation with 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. All vasoactive drips can cause severe tissue injury if infiltration occurs. It should also be considered to have arterial line pressure monitoring for patients on vasoactive drips. A physician's order is needed to administer any vasoactive drip, and the order should include parameters to titrate related to heart rate, blood pressure, respiratory rate, and oxygen saturation if indicated. Healthcare providers must know the maximum dose, the minimum dose, the titration parameters, and side effects for all critical care drips and infusions.

Remember that cardiac output is the holy grail of hemodynamics. To maintain blood pressure and heart rate, cardiac output must be sustained. Cardiac output is defined by the stroke volume times the heart rate (SV X HR). The cardiac output is a vital part of oxygen delivery, blood pressure, urine output, and perfusion.

There are many drugs used for hemodynamic instability, cardiogenic shock, and neurogenic shock. Norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, and dobutamine are a few of the medications used. Volume loss and hypovolemia should be corrected before the administration of any vasopressor. If the fluid status is unknown, then continue close hemodynamic monitoring to determine the efficacy of the vasoactive drip.1 Vasoactive drips will only temporarily correct hypovolemia, and then the patient will become unstable again until the fluid volume status of the patient is corrected. All critical care drips must be on an infusion pump. All patients on vasoactive medications must be on a continuous heart monitor, along with blood pressure and oxygen saturation monitoring. Emergency resuscitative equipment and medications should always be immediately available to manage any unwanted medication reactions.2

Vasoactive Drip Calculations

Pre-Mixed Dopamine

Here is the basic equation for formulating, mixing, and calculating drip rates. For the purpose of 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.3

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

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 an increase in 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 and/or SBP >90. Vital signs are monitored continuously and documented every 5 minutes during titration.

LEVOPHED CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)
Dose Ordered MCG/MINLevophed 4 mg/250 mlSpecial Instructions
0.51.9 ml/hrProtect from light
13.8 ml/hrTitrate up every 20 min
27.5 ml/hrIncompatible with NAHCO3
311.3 ml/hrImmediate onset
415 ml/hrHalf-life 1-2 minutes
518.8 ml/hrCan cause arrhythmias
622.5 ml/hrIncreases cardiac 02 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 MAOI therapy
30112.5 ml/hrCocaine use causes HTN

Scenario:

A 54 y/o male presents to the ER with a complaint 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 an increase in 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, Saturation 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 parameters.

Epinephrine

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.

EPINEPHRINE CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)4
Dose ordered MCG/MINEpinephrine
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 HTN and arrhythmias
575 ml/hrMonitor pulses with vasoconstriction
690 ml/hrHigh doses can cause myocardial ischemia
7105 ml/hrKeep patient on cardiac monitor
8120 ml/hr

 

9135 ml/hr

 

10150 ml/hr

 

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, starts oxygen administration with a bag-mask bag and 100% oxygen, and starts 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 and heart rate >80 and heart rate <110.

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

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

DOPAMINE CHART (verify all doses, concentrations, and titration policies with MD and facility pharmacy)

Dose ordered mcg/kg/min

75kg80kg85kg90kg95kg100kg
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 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.

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 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

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. This drug can cause tachycardia and headache. It is contraindicated in patients with sulfite allergy Onset 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.

DOBUTAMINE CHART
(verify all doses, concentrations, and titration policies with MD 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 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 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

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 to constrict blood vessels, thereby increasing blood pressure and 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 the use of 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 MD and facility pharmacy)
Dose ordered units/minuteVasopressin 20 units/100 mlSpecial Instructions
0.01 u/m3 ml/hrMetabolized by kidneys/liver
0.02 u/m6 ml/hrSevere vasoconstriction
0.03 u/m9 ml/hrFirst alternative to epinephrine
0.04 u/m12 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:

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, 1 liter of normal saline is administered. She is making about 10 ml of urine an hour. The doctor orders 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.4

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 reversed quickly. Nipride is cyanide toxic; signs and symptoms of toxicity possibly being that of altered blood ph and mental status changes.5 To prevent cyanide toxicity, thiocyanate levels must be monitored. It is mixed 50 mg in 250ml D5W (200mcg/ml). The dose is 0.3-10 mcg/kg/min and slowly titrated until MAP decreases 5-10mmHg. It cannot be stopped abruptly, as this may cause rebound hypertension and seizures. If treating a patient for a hypertensive crisis, MAP should be reduced by no more than 25% over the first hour. Doses may be titrated every 5-10minutes.5

NIPRIDE CHART
50 mg/250 mL D5W (verify all doses, concentrations, and titration policies with MD/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, 75kg, 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 doctor wants to start a drip to control the blood pressure. The best vasodilator choice for hypertensive crisis is __________________?

  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 5mcg/kg/min. for 20 minutes. His B/P is now 192/100, HR is 84, and his oxygen saturation is 98%. The physician orders the Nipride drip to be titrated to keep the diastolic blood pressure less than 90, and the heart rate greater than 60 and less than 120. What is the next 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 0.3-10 mcg/kg/min and slowly titrated until MAP decreases 5-10mmHg. It cannot be stopped abruptly, as this may cause rebound hypertension and seizures. If treating a patient for a hypertensive crisis, MAP should be reduced by no more than 25% over the first hour. Doses may be titrated every 5-10minutes. The next titration dose on the chart is 7mcg/kg/min. This is a standard dose as recommended by AHA-ACLS guidelines.4 Each facility has its policies and follows the physician’s orders, but when in doubt, check with the pharmacist and suggest that a consult with a cardiac specialist or other specialists depending on the circumstances may be applicable.

Nitroglycerin

Nitroglycerin is a nitrate and a strong vasodilator, dilating coronary arteries and decreasing preload. It is classified as an anti-anginal and antihypertensive drug, as well as 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 MI. It is always prepared in a glass bottle with vented tubing. It usually comes premixed 50 mg/250ml D5W equaling 200 mcg/ml. The standard starting dose is 10-20mcg/min or 3-6ml/hr. Caution must be used in the presence of oral nitrates, inferior wall MI and sexual performance-enhancing drugs as life-threatening hypotension can ensue. It can cause severe bradycardia and hypotension.

NITROGYLCERIN CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)
Dose Ordered MCG/MINNitroglycerin 50 mg/250 ml D5WSpecial Instructions
51.5 ml/hrUse glass bottle
103 ml/hrUse vented tubing
206 ml/hrCeiling dose of 200 mcg/min
309 ml/hrMay 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:

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. He is 100% saturate on 2 liters 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, dilating coronary arteries, and decreasing preload. It is classified as an anti-anginal and antihypertensive drug, as well as 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 MI.

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

  1. True
  2. False

Rationale:

Nitroglycerin administration is used cautiously in the presence of oral nitrates, inferior wall MI 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 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.

55y/o male comes to the ER with chest pain and left jaw pain for 20 min. 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 3 sublingual nitroglycerines. His troponin is severely elevated. His current blood pressure is 156/79. The doctor orders nitroglycerin 50mg/250ml at10 mcg/min. How many ml/hr will the pump be set?

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

Rationale:

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

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

Antiarrhythmics

Diltiazem

Diltiazem (Cardizem) is a calcium channel blocker and anti-arrhythmic for heart rate control during atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and atrial fibrillation with a rapid ventricular response. Do not use 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, 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.

DILTIAZEM CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)
Dose ordered mg/hrDiltiazem
125 mg /100 ml NS
Special Instructions
55 ml/hrCan cause severe hypotension
1010 ml/hrCan cause hypocalcaemia
1515 ml/hrCalcium is antidote
2020 ml/hrMonitor B/P 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 anti-arrhythmic 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 anti-arrhythmic used for rate control in atrial fibrillation. Its mechanism of action is the slowing of 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 anti-arrhythmic for heart rate control during atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and atrial fibrillation with a rapid ventricular response. Do not use for wide complex QRS tachycardias. The anti-dote 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 in 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 patients' vital signs are 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

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 anti-arrhythmic. 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.

AMIODARONE CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)
Dose ordered after bolus of 150 mg or 300 mgAmiodarone 1.8 mg/ml 450 mg/250 ml D5WMaintenance InfusionSpecial Instructions
1 mg/minute33 ml/hr for 6 hrs.360 mg over 6 hrsMonitor B/P
0.5 mg/min16 ml/hr for 18 hrs.540 mg over 18 hrs.Monitor QT interval

Scenario:

A 65 y/o male presents to the ER via ambulance in 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 anti-arrhythmic.

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 a 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 is exhibiting 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 anti-arrhythmic should be ordered.

Rationale:

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

Lidocaine

Lidocaine (Xylocaine) is a ventricular anti-arrhythmic medication. It is usually premixed but should be 2grams/500ml D5W, 4mg/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 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, and tinnitus, as well as 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.6 The drug is still considered a primary medication for use in ACLS and is given equal consideration with amiodarone per Craig-Brangen and Day.4

LIDOCAINE CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)/span>
Dose ordered mg/minLidocaine 2 grams/500 mlSpecial Instructions
115 ml/hrMonitor for bradycardia
230 ml/hrDo not use in AMI
345 ml/hrMonitor for heart block
460 ml/hrWatch for circulatory depression

Scenario:

A 65 y/o female patient is on lidocaine 2mg/min for ventricular tachycardia of 160. The bedside alarm is indicating 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 anti-arrhythmic 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

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, which will decrease the 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 secondary to its very 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, of heart rate control, cautiously monitoring blood pressure during titration. Do not stop the medication abruptly.

ESMOLOL CHART
(verify all doses, concentrations, and titration policies with MD and facility pharmacy)
Esmolol 2.5 grams/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
7534ml/hr36 ml/hr38 ml/hr41 ml/hr43 ml/hr
10045ml/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
250112.5ml/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, 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 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 anti-arrhythmic. 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 anti-arrhythmic 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 nest 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, for 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, of heart rate control, cautiously monitoring blood pressure during titration. Do not stop the medication abruptly.

The same patient now 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

Adenosine is used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. It is an anti-arrhythmic. 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. There is evidence to support both inhibition 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 anti-arrhythmic.

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 anti-arrhythmic. 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 anti-arrhythmic. 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 the successful correction of 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.

How To Use the Drug Calculation Formula

Ordered amount of drug x patients' weight in kg x60 minutes/Drug concentration (mg divided by ml) then multiply x 1000 for mcg
= ml/hr

 

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

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

5x75x60/400/250x1000 (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
  • 75kg is the patient weight
  • 60 minutes (# of minutes in an hour)
  • 400mg of dopamine in 250ml D5W (change mg to mcg/1mg=1000mcg)

 

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

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

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

 

Here is an explanation of each element:

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

 

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

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

2x60/2/500x1000 (2 grams must be converted to mg) 4 mg/ml
= 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 grams of lidocaine in 500ml D5W (change grams to mg/ 1gram=1000mg)

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

Conclusion

Remember that all vasoactive medications are dose-dependent and need to be administered cautiously. All patients on vasoactive drips need ECG monitoring, blood pressure monitoring, and oxygen saturation monitoring continuously. All critical care and emergency drips must be administered on an infusion pump. Elderly patients and patients with multiple co-morbidities respond differently and need to be monitored constantly. All vasoactive drips should be administered via central access. Peripheral access may be used until central access is obtained; however, all vasoactive drips cause severe tissue injury if extravasation occurs.2 An arterial line is preferred for constant blood pressure monitoring. It is imperative to remember that all medications for hypotension need to be administered while considering fluid volume loss and the need for fluid resuscitation. Many of the vasoactive medications, while can be of great value to the patient they can also cause life-threatening arrhythmias. Cardiac monitoring is essential while administering these medications. Correction of glucose levels and acidosis is important to ensure the efficacy of the vasoactive drip.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Greenwood, John. PressorDex. Irving: EMRA, 2013. Print.
  2. Castano, FC. Emergency Medicine. 6th ed. Washington: American College of Emergency Physicians, 2012. Print.
  3. JBF/KRR/AKW Vasoactive drip calculations Retrieved October 4, 2015. Visit Source.
  4. Craig-Brangen, Karen and Day, Mary Patricia. Update: 2017/2018 AHA BLS, ACLS, and PALS guidelines. Nursing2019: February 2019 - Volume 49 - Issue 2 - p 46-49.
  5. Karim, M.I. Khan, M.S. Panhwar, F. Nadeem, D. Carroll, A. Kalra. Cyanide Toxicity at "Safe" Dose of Sodium Nitroprusside Within 24 Hours of Treatment. Visit Source.
  6. Mrad S, El Tawil C, Sukaiti WA, Bou Chebl R, Abou Dagher G, Kazzi Z. Cardiac Arrest Following Liposuction: A Case Report of Lidocaine Toxicity. Oman Med J. 2019;34(4):341–344. doi:10.5001/omj.2019.66