You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

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

3.00 Contact Hours
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Tosca R. Moore (RN, BSN)

Outcomes

To provide a guideline for ordering, dosing, and titrating cardiovascular and critical care medications in the critical care unit.

Objectives

The participant will be able to:

  1. Determine when vasoactive medications are indicated.
  2. Know 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 the critically ill patient.
  5. Describe how to calculate and verify drug mixtures each and every time a critical drug is administered. 

Definitions

Titration: increasing or decreasing a vasoactive drug or other critical 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 heart muscle (myocardial contractility); negative inotropes decrease cardiac workload and blood pressure, positive inotropes increase cardiac workload and blood pressure. (Negative inotropes are beta blockers, diltiazem and verapamil. Positive inotropes are dopamine, dobutamine, epinephrine and norepinephrine)

Catecholamine: any of a class of aromatic amines that includes a number of neurotransmitters which cause sympathomimetic action (epinephrine, norepinephrine, Dopamine, Dobutamine)

Adrenergic: having characteristics of secreting epinephrine or substances with similar activity (epinephrine and norepinephrine)

Introduction

The use of vasoactive medications in the emergency room and intensive care units can be a daunting task. Nurses working in the acute setting need knowledge of the pathophysiology of shock, sepsis, cardiac arrhythmias and other acute onset critical illnesses. They need to know the pharmacology of vasoactive drugs to enable them to safely administer and care for the critically ill patient.  Additionally, unit policies on medications and titration policies will determine the delivery, dosage and titration for each patient. The focus on patient safety is paramount to administering any vasoactive drip. Most hospitals have pharmacy mix all the critical care drip infusions. Many drug companies are following suit and provide pre-made drip kits and drip rate matrix with each medication. Today’s technology has taken the guess work out of drug calculations and drip rates but even with smart pumps available every nurse should calculate and verify drug mixtures each and every time a critical drug is administered.  Elderly patients respond differently and should be monitored closely.  Young adults and pediatric patients respond quickly to critical care drips. The safety of all the medications has not been established in pregnant women and their use is not recommended unless there is no other therapy.

Vasoactive medications are indicated when the Systolic Blood Pressure (SBP) has a decrease of > 30 mm Hg from the baseline or a Mean Arteriole Pressure (MAP) less than 65 mm Hg and when either condition results in end-organ dysfunction due to hypo perfusion. Additionally vasoactive medications are used for management of hypertensive crisis, flash pulmonary edema, sepsis, shock, atrial fibrillation with rapid ventricular response, supraventricular tachycardia, heart failure and hemodynamically unstable patients.

Vasopressors should be infused via central access but may be administered peripherally until central access is obtained. All vasoactive drips can cause serious 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 saturation if indicated.  It is imperative for healthcare providers to know the maximum dose, the minimum dose and titration parameters for all critical care drips and infusions.

Remember that cardiac output is the holy grail of hemodynamics.  In order to maintain blood pressure and heart rate, the cardiac output must be sustained.   The cardiac output is part of each vital sign, oxygen delivery and saturation, blood pressure, urine output, and perfusion. In order to increase the blood pressure the Systemic Vascular Resistance (SVR) or cardiac output can be increased. 

There are many drugs used for hemodynamic instability and cardiogenic and neurogenic shock.  Norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, and dobutamine are a few of the medications used.  Volume loss and hypovolemia should be corrected prior to the administration of any vasopressor.  If fluid status is not known, then continue close hemodynamic monitoring to determine the efficacy of the vasoactive drip. Vasoactive drips will only temporarily correct hypovolemia; then, the patient will become unstable again until fluid volume status of patient is corrected.   All critical care drips must be on an infusion pump.  All patients on vasoactive medications must be on continuous monitoring of heart rate, blood pressure and oxygen saturation. Emergency and resuscitative equipment and other medications should always be immediately available to manage any unwanted medication reactions

Vasoactive Drip Calculations

Dopamine and Dobutamine (Rule of 15):

  • Concentration: 1 mL/hr = 1 mcg/kg/min
  • 15 X Patient's weight (kg) = mg of drug in 250 mL NS or D5W

Example: 10 kg child
<>?15 X 10 = 150 mg in 250 mL Solution: 1 mL/hr = 1 mcg/kg/min

<>Epinephrine [Rule of 15 (1.5 and 0.15)]:

  • Concentration: 1 mL/hr =
  • 1.5 X Patient's weight (kg) = mg of drug in 250 mL NS or D5W

Example: 10 kg child

<>1.5 X 10 = 15 mg in 250 mL: 1 mL/hr = 0.1 mcg/kg/min

  • Concentration-1 mL/hr =
  • 0.15 X Patient's weight (kg) = mg of drug in 250 mL NS or D5W

Example: 10 kg child

0.15 X 10 =1.5 mg of drug in 250 mL: 1 mL/hr = 0.01 mcg/kg/min

Pre-Mixed Dopamine:

  • CHET Bag Concentration for Dopamine: (200 mg/250 mL solution) x 1000 = 800 mcg/mL

To get 1 cc/hr equals how many mcg/kg/min:

  • (mg of Dopamine/cc of solution x 1000)/Kg Wt./60min

Example: For a 10 kg patient

(200 mg/250 cc x 1000)/10/60 or 800/10/60 = 1.333 1 cc = 1.333 mcg/kg/min

For All Pre-mixed Drugs to get mL/hr on the pump:

  • Desired dose in mcg/kg/min x kg wt. x 60 min/hr800 mcg/mL*

CHET Bag Concentration for Dopamine: (200 mg/250 mL solution) x 1000 = 800 mcg/mL

Remember to use different concentrations for different pre-mixed drugs

Example: To get 5 mcg/kg/min for a 10 kg patient:

(5 mcg/kg/min x 10 kg x 60 min/hr = 3.75 mL/hr 800 mcg/mL (Set Pump at 3.75 mL/hr to get 5 mcg/kg/min)

(JBF/KRR/AKW 09/03/2008)

The following 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.

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 4 mg levophed in 250 mL of D5W making the drip 16 mcg/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 >65 mm Hg or SBP>60. 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 16 g 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 in 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 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 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)
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 (epi) 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: MD orders Epinephrine 2 mcg/min titrate for SBP>100 and heart rate >80 and heart rate <110.

This medication is mixed at 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 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 20 mcg/min. High doses improve patient outcomes after PEA and asystole.

  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 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 cc/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 5 mcg/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/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/min75 kg
80 kg
85 kg
90 kg
95 kg
100 kg
514 mL/hr
15 mL/hr
16 mL/hr
17 mL/hr
18 mL/hr
19 mL/hr
7.521 mL/hr
23 mL/hr
24 mL/hr
25 mL/hr
27 mL/hr
28 mL/hr
1028 mL/hr
30 mL/hr
32 mL/hr
34 mL/hr
36 mL/hr
38 mL/hr
1542 mL/hr
45 mL/hr
48 mL/hr
51 mL/hr
53 mL/hr
56 mL/hr
2056 mL/hr
60 mL/hr
64 mL/hr
68 mL/hr
71 mL/hr
75 mL/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 30 mL/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 5 mcg/kg/min. The patient has a history of diabetes and fibromyalgia. She weighs 75 kg and is 5’ 7” feet tall. Her heart rate is 80 and 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: MD 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 important. 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 400 mg in 250 cc/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 5 mcg/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 30 m:/hr. The physician orders the drip to be titrated down by 5 mcg/kg/min every half hour as long as SBP >100. The drip is decreased to 10 mcg/kg/min. 45 minutes later the patient has a heart rate of 110, and a blood pressure is 90/58. What is the next action of the nurse?

  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 written parameters and re-verify orders if in doubt.

Dobutamine

Dobutamine is adrenergic agonist and first line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts like a chemical balloon pump-reduces afterload but increases 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. The onset is 1-2 minutes and half-life is 2 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 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 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, 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 adrenergic agonist and first line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension.

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

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

Rationale: Dobutamine is adrenergic agonist and first line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts like a chemical balloon pump-reduces afterload but increases 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 30 mL/hr. He weighs 85 kg. His oxygen saturation is 92% on 40% face mask. He is able to 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. The bedside cardiac monitor, two minutes after the infusion is started, shows a heart rate of 126, saturation 90% and a blood pressure of 72/34. The next action of the nurse is?

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

Rationale: Dobutamine is adrenergic agonist and first line inotropic. Dobutamine is used for cardiogenic shock and associated hypotension. It acts like a chemical balloon pump-reduces afterload but increases 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 rapid fluid bolus of 3 liters. The urine output has increased to 60 mL/hr. The cardiac monitor indicates a sinus rhythm of 89, an oxygen saturation of 96% on 40% face mask, and a 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, 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 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 half-life is 2 minutes. The vital signs are in parameters. This drug is fast acting and vital signs are done continuously on the bedside monitor and documented frequently. Each facility has a policy on frequency of vital sign documentation. Every five -15 minutes is standard.

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 reaction of arrhythmias, cardiac arrest, angina, myocardial ischemia, and peripheral constriction. This is 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%. Levofloxin 750 mg IV is administered, blood cultures are ordered, and 1 liter of normal saline is administered. She is making about 10 mL 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 which medication?

  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.

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. It must be protected from light. It acts quickly and is reversed quickly. It is cyanide toxic and thiocyanate levels must be monitored. It is mixed 50 mg in 250mL D5W (200 mcg/mL). The dose is 0.3-10 mcg/kg/min and slowly titrated until MAP decreases 5-10 mm Hg. It cannot be stopped abruptly as this may cause rebound hypertension and seizures. If treating a patient for hypertensive crisis, MAP should be reduced by no more than 25% over the first hour. Doses may be titrated every 5-10 minutes.

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. Nipride 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 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 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 5-10 mm Hg. It cannot be stopped abruptly as this may cause rebound hypertension and seizures. If treating a patient for hypertensive crisis, MAP should be reduced by no more than 25% over the first hour. Doses may be titrated every 5-10 minutes. The next titration dose on the chart is 7 mcg/kg/min. This is a standard dose as recommended by AHA-ACLS guidelines. Each facility has its own policies; follow the physician’s orders but when in doubt check with the pharmacist and suggest that a consult with a cardiac specialist or other specialist, dependent 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/250 mL NS 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 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 NSSpecial 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 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 10 mcg/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 prior to 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 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 50 mg/250 mL at10 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 = 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 rapid ventricular response. Do not use for wide complex QRS tachycardias. The anti-dote for diltiazem is calcium. It is mixed as a 1:1 drip. It is mixed 125 mg/100 mL NS. The 125 mg of Diltiazem is 25 mL volume making the drip 125 mg/125 mL. An initial bolus, for acute rate control, of 5 mg-20 mg (0.25 mg/kg over 2 min; if inadequate response, 0.35 mg/kg over 2 minutes) intravenous push is usually administered to evaluate 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 physiologically appropriate heart rate is reached. Caution is to be used in patients with; AVB > 1°, WPW syndrome, ventricular tachycardia, SSS, short PR syndrome. Blood pressure must be monitored every five minutes as Diltiazem will rapidly decrease blood pressure. Start low and go slow with diltiazem. Most patients respond well to 5 mg 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 rapid ventricular response.

The drug of choice for atrial fibrillation is Diltiazem. It is a calcium channel blocker. The usual loading dose is?

  1. 10 mg
  2. 30 mg
  3. 40 mg
  4. 50 mg

Rationale: An initial bolus of Diltiazem for atrial fibrillation for acute rate control of 5 mg-20 mg (0.25 mg/kg over 2 min; if inadequate response, 0.35 mg/kg over 2 minutes) intravenous push is usually administered to evaluate response and blood pressure tolerance.

Diltiazem is an anti-arrhythmic used for rate control in atrial fibrillation. It’s mechanism of action is the slowing of calcium in vascular and cardiac muscle tissue. What is the anti-dote 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 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 10 mg 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. 125 mg (25 mL) of Diltiazem is mixed in 125 mL of normal saline. The 1:1 drip is ordered to infuse at 5 mg/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 heart rate of 133 and 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: An initial bolus, for acute rate control, of 5 mg-20 mg (0.25mg/kg over 2 min; if inadequate response, 0.35mg/kg over 2 minutes) intravenous push is usually administered to evaluate response and blood pressure tolerance. The drip is then started at 5 mg/hr (5mL/hr) and titrated up by 2-5 mg 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 100 mL D5W over 10 minutes, may also be used for VF, VT and cardiac arrest unresponsive to CPR. The a drip is mixed 450 mg/250 mL D5W and runs at 1 mg/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 20 mg IVP.

  1. True
  2. False

Rationale: 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 100 mL D5W over 10 minutes, may also be used for VF, VT and cardiac arrest unresponsive to CPR.

An Amiodarone 300 mg bolus is followed by a continuous drip infusion. The Amiodarone drip will infuse for how many 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 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.

Lidocaine

Lidocaine (Xylocaine) is a ventricular anti arrhythmic medication. It is usually premixed but should be 2 grams/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 arrhythmia by decreasing automaticity. The onset is 30-90 seconds. Use caution in the elderly as completed heart block can occur. It can also cause confusion, hypotension, lightheadedness, diplopia, seizures, and tinnitus. It is contraindicated in complete or 2nd degree AV block and the dose needs to be decreased for those patients with congestive heart failure or hepatic disease.

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

Lidocaine is used for ventricular ectopy and is an anti-arrhythmic. It decreases cardiac automaticity.

  1. True
  2. False

Rationale: Lidocaine (Xylocaine) is a ventricular anti-arrhythmic medication. It is usually premixed but should be 2 grams/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 arrhythmia by decreasing automaticity.

Scenario

A 65 y/o female patient is on lidocaine 2 mg/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: Use caution in the elderly as completed heart block can occur. It can also cause confusion, hypotension, lightheadedness, diplopia, seizures, and tinnitus.

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. This 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 bolused secondary to its very quick onset. If a bolus is desired, 250-500 mcg/kg undiluted may give IV push over one minute. Mix 2.5 grams Esmolol in 250 mL D5W equaling 10 mg/mL. The drip may be started at 50 mcg/kg/min and titrate up to 300 mcg/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 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 less than 110, and greater than 60, and to keep SBP<160 and >90. She has NKA and her weight is 90 kg. 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 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, control heart 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 50 mcg/kg/min and titrate up to 300 mcg/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 60 mL/hr. The Esmolol remains at 75 mcg/kg/min. What is the next action of the nurse?

  1. Increase drip to 80 mcg/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.

24 hours later the same patient remains in the ICU. The Esmolol drip is at 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. 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 an anti-arrhythmic used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome. This type of arrhythmia is deadly. Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10 mL Normal Saline flush immediately after intravenous push is administered for PSVT.  If not effective within 1-2 minutes, a second 12 mg bolus may be given; 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 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 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 administration of Adenosine.  Patients frequently complain of chest pain and shortness of breath after 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 an anti-arrhythmic used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome.  This type of arrhythmia is deadly.

What is amount of the first dose of adenosine?

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

Rationale:  Adenosine is an anti-arrhythmic used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome.  This type of arrhythmia is deadly.  Initially, an adenosine 6 mg rapid bolus (over 1-2 seconds) with a 10 mL Normal Saline flush immediately after intravenous push is administered for PSVT.  If not effective within 1-2 minutes, a second 12 mg bolus may be given; 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 an anti-arrhythmic used to treat paroxysmal supraventricular tachycardia and Wolff- Parkinson-White Syndrome.  This type of arrhythmia is deadly. 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. 6 mg
  2. 12 mg
  3. 18 mg
  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: MD orders dopamine 5 mcg/kg/min titrate to keep SBP>100 and MAP>65. The hospital pharmacy has premixed Dopamine 400 mg/250 L 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 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)

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

This medication is mixed at 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: MD orders Lidocaine 2 mg/min titrate for ventricular ectopy, maintaining heart rate >60 and SBP>90. The hospital has premixed Lidocaine 2 grams/500 mL 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
  • The kg # is omitted as the medication is NOT weight based
  • 60 minutes (# of minutes in an hour)
  • 2 grams of lidocaine in 500 mL D5W (change grams to mg/ 1 gram = 1000 mg)

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. 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, 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.

References

Fergusson, A., and R. Tipping. "Inotropes and Vasopressors." ABC of Transfer and Retrieval Medicine (2014): 96.

Hollenberg, Steven M. "Inotrope and vasopressor therapy of septic shock." Critical care nursing clinics of North America 23.1 (2011): 127-148.

2015 Handbook of Emergency Cardiovascular Care (ECC) for Healthcare Providers (2015 Handbook of ECC)

Karch, Amy M.,2015 Lippincott Pocket Drug Guide for Nurses, edition 3, Lippincott Williams & Wilkins, 2014

Carlson, Karen. AACN Advanced Critical Care Nursing. St. Louis: Saunders/Elsevier, 2009. Print.

Castano, FC. Emergency Medicine. 6th ed. Washington: American College of Emergency Physicians, 2012. Print.

Chawla, Rajesh. ICU protocols a stepwise approach. Dordrecht: Springer India, 2012. Print.

Christopher, Overgaard. Inotropes and Vasopressors. Dallas: AHA/Lippincott, 2011. Print.

Chulay, Marianne, and Suzanne Burns. "Pharmacology Tables." AACN Essentials of Critical Care Nursing. 2010 ed. New York: McGraw Hill Medical, 2010. Chapter 23. Print.

Field, John M., Mary Fran Hazinski, and David Gilmore. Handbook of emergency Cardiovascular care for healthcare providers. Dallas, TX: American Heart Association, 2006. Print.

Greenwood, John. PressorDex. Irving: EMRA, 2013. Print.

Hazinski, Mary Fran, Ricardo Samson, and Steve Schexnayder. 2010 Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, TX: American Heart Association, 2010. Print.

JBF/KRR/AKW Vasoactive drip calculations Retrieved October 4, 2015 (Visit Source)

Reynolds, Ira Gene. Calculating I.V.drip rates with confidence. Philadelphia: American Nurse Association, 2006. Print.

Terry, Cynthia Lee, and Aurora L. Weaver. Critical care nursing demystified. New York: McGraw Hill Medical, 2011. Print.

Thaemert, Nelson L., Charles E. Hobson, and Curtis G. Tribble. ICU recall. 3. ed. Philadelphia: Lippincott Williams & Wilkins, 2009. Print.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, Critical Care / Emergency Care


Last Updated: