CARDIAC DRIPS

AMIODARONE

❖ MOA: Slows sinus rate, ↑ PR and QT intervals, ↓ peripheral vascular resistance (vasodilation)
❖ Indications:
➢ Ventricular dysrhythmias: Vfib, Pulse & pulseless Vtach, PVCs
➢ Some atrial dysrhythmias: SVT & Afib
❖ Administration:
➢ Pulse:
1. Loading dose: 150 mg in 100 mL D5W IVPB - infused over 10 minutes (600 ml/hr)
2. Infusion: 900 mg in 500 mL D5W
1. Infused over 6 hours (33.3 ml/hr or 1 mg/min)
2. Infused over 18 hours (16.7 ml/hr or 0.5 mg/min)
● Infusion is 24 hours total
➢ Pulseless:
■ Bolus: IVP
1. 300 mg IVP
2. 150 mg IVP (if pt has not converted to a normal rhythm)
❖ Compatibility:
✓ Compatible:
■ D5W & NS for 24 hours ■ Lasix (low doses)
■ Procainamide ■ Lidocaine
■ Verapamil ■ KCl
■ Dobutamine
✖ Incompatible:
■ Tikosyn ■ Aminophylline
■ Heparin ■ Digoxin
■ Bivalirudin ■ Many ABX
■ Sodium Bicarb
❖ Contraindications:
➢ Tikosyn → ↑ effect of both drugs
■ Call Dr to suggest an alternate medication
➢ Poor IV access → Severe infiltration & tissue damage
❖ Adverse Effects:
➢ Infiltration
➢ Bradycardia
➢ Hypotension
❖ Nursing:
➢ Mix bolus gently to avoid foaming
➢ Filter: needed for infusion, not for bolus
■ Attachment to tubing - Get filter in med room or request it from pharmacy
➢ Do NOT just stop drip after 24 hours
■ Contact Dr to check if they want to continue or DC drip
● May bridge them over to PO Amiodarone
● Contact Dr before the 24 hours is up so you can order the Amiodarone (if needed)
and have enough time for it to arrive from pharmacy
➢ Conditional order: Infusion is conditional order, Bolus is not
■ Call Dr if you suspect pt will need Amiodarone → Dr will order Amiodarone order set
■ Order set include: Bolus orders & Conditional order for infusion
● Call Dr to inform them that you are activating the conditional order for the drip
 ● Activate the order
➢ Get rhythm strips & VS before, during, and after administration
➢ IV/Central Line:
■ If peripheral IV is being use, monitor it thoroughly to catch any signs of infiltration early
■ If infusion > 24 hour, consider a central line
➢ If infiltration occurs:
■ STOP infusion
■ Keep IV in for antidote infusion if applicable
● Do not use that IV anymore for anything else
■ Slowly aspirate as much of the med as possible
■ Do not apply pressure
■ Call Dr & pharmacy
■ Elevate for 48 hr to ↓ swelling
■ Initiate substance specific measures
■ Trace border of area
● Assess for growth Qshift & PRN
■ Observe for pain, induration & necrosis
■ Warm/cold therapy as ordered
■ Avoid further trauma, pressure & IV therapy
■ Tell pt to resume activity with that limb as tolerated
■ Chart in IV complications parameter
➢ Documentation:
■ Amiodarone IV Parameter in VS flowsheet
● VS, rate, dose adjustment
■ Infiltration → IV complications in IV/Lines flowsheet
● Chart until IV complications have resolved
 CARDIZEM

❖ MOA: Inhibits transport of Ca into myocardial & vascular muscle cells → inhibition of excitation
→ ↓ HR, ↓ BP (vasodilation)
❖ Indications:
➢ ↓ ventricular rate in Afib/flutter (RVR) & SVT
■ HR > 120 for > 30 min or symptomatic (lightheaded, CP, dyspnea, dizzy, HoTN)
➢ Peripheral vasodilation → ↓ BP
➢ Coronary vasodilation → ↓ frequency & severity of angina
➢ Goal: HR 90-120 or conversion to NSR (whichever comes first), if not otherwise specified by
physician.
❖ Metabolism:
➢ Immediate release - Onset: 2-5 min, Peak: 2-4 hr
➢ Extended release - Peak: 10-18 hr
❖ Dosages:
➢ IV Bolus: 25 mg/5 mL in vials
➢ IV Drip: 125 mg/125 ml or 1 mg/1 ml D5W
■ Supplied by pharmacy - comes via tube system
❖ Administration:
1. Initial bolus: 0.25 mg/kg over 2 minutes IVP
■ Max: 20 mg
■ If HR & rhythm goal is met → begin infusion
2. Repeat bolus: 0.35 mg/kg over 2 min IVP
■ Do repeat bolus if initial dose is inadequate after 15 min
■ Max: 25 mg
■ If HR & rhythm goal is met → begin infusion
3. Infusion: begin as ordered, then ↑ by 5 mg/hr q15 min
■ Max: 15 mg/hr
● > 15 mg/hr does not ↑ effectiveness
➢ How to STOP infusion: Titrate down
■ Discuss transition to PO with pharmacy before stopping IV
❖ Contraindications:
✴ Infusion > 24 hours or rates > 15 mg/hr are not recommended
➢ Symptomatic HoTN
➢ SBP < 90
➢ Acute MI with pulmonary congestion on x-ray
➢ Administration of IV beta-blockers within a few hours of IV Diltiazem
➢ Afib/flutter associated with an accessory bypass tract (Wolff-Parkinson-White or short PR
syndromes); Risk of potentially fatal heart rate fluctuations
➢ Heart block - 2nd or 3rd degree AV w/o functioning ventricular pacemaker
➢ Sick sinus syndrome w/o functioning ventricular pacemaker
❖ Nursing:
➢ Get rhythm strips & VS before, during & after administration
■ Continuous cardiac monitoring required
➢ Call Dr and hold dose for SBP < 90 mmHg or as determined by MD order/parameter
➢ Documentation: Cardizem IV parameter in VS flowsheet - Document VS, rate, and titration
■
 Nitroglycerin
❖ MOA:
➢ Dilates coronary arteries & improves collateral flow to ischemic regions → ↑ coronary blood flow
➢ Vasodilation (venous more than arterial) → ↓ preload & afterload
➢ ↓ myocardial O2 consumption
❖ Indications:
➢ Initial antianginal for suspected ischemic pain
➢ CHF associated with acute MI
➢ Hypertensive urgency with Acute Coronary Syndrome
❖ Metabolism:
➢ Onset: immediate
➢ Half life: 1-4 minutes (quick on/off - short half life)
➢ Metabolized without dependence of kidney function
❖ How it’s supplied:
➢ 25 mg/250 mL glass bottle
➢ Stable for 48 hours at room temp
➢ Don’t forget to vent infusion set
❖ Administration:
➢ Max rate: Max: 20 mcg/min
➢ Chest Pain (be aggressive)
■ Begin at 5 mcg
■ Titrate every 2 minutes - ↑ by 5mcg/min until goals met or 20 mcg/min is reached.
■ If goals of therapy are not met at 20 mcg/min → may increase by 10 mcg/min as often as every 2
minutes until:
● Goals are met OR max rate is reached OR pt’s BP drops < 90
■ Max dose on Cardiac Units: 100mcg/min.
■ If patient cannot meet the goals of therapy → call MD for orders.
➢ HTN (be cautious)
■ Begin at 5 mcg/min
■ Titrate by 5 mcg/min q2min until goal or max rate reached
■ Goal must be specified by MD
● Do not overshoot goal BP – lower is not better!!
➢ How to STOP infusion: Titrate down
■ DO NOT MAKE ANY ABRUPT CHANGES
● Titrating down too quickly → Rebound HTN
■ Wean off the same way as titrating up
❖ Contraindications:
➢ HoTN < 90 or ≥ 30 below baseline
➢ Severe anemia
➢ Head trauma or cerebral hemorrhage
➢ Pericardial tamponade
➢ Restrictive CMO
➢ Right ventricular infarction
➢ Use of phosphodiesterase inhibitors (Viagra within 24 hours or Tadalafil within 48 hours)
❖ Adverse Effects: HoTN - can cause further damage to the heart.
❖ Nursing:
✴ Hemodynamic & antianginal tolerance develops after 24-48 hours of continuous infusion
✴ DO NOT MAKE ANY ABRUPT CHANGES - Titrate up and down -
■ Turning it up to quickly → HoTN
■ Turning it down or off too quickly → Rebound HTN
➢ Do not reduce SBP < 90 (per SMH policy)
➢ Do not mix with other drugs
➢ Check for IV compatibility for Y-site infusion
➢ Patient should sit or lie down when on this medication
➢ Documentation: Add Nitroglycerin IV parameter in VS flowsheet - document VS, rate & titration