IV Infusion Drugs ACLS Drugs Steven Wright MSN

IV Infusion Drugs ACLS Drugs Steven Wright, MSN, RN Coordinator, Education/Cardiac Rehab South Baldwin Regional Medical Center

Objectives l l Determine the indications for use of various intravenous drugs Be familiar with mixing and infusion parameters for each drug Identify precautions and contraindications of each drug Review nursing considerations for IV drug infusion

AMIODARONE (Cordarone) l Dose – – l Bolus: 150 mg over 10 min Drip: 1 mg/min x 6 hrs, then 0. 5 mg/min x 18 hrs ACLS Dose – l Antiarrhythmic 300 mg IVP, 150 mg IVP Mix – – Bolus: 150 mg in 100 ml D 5 W Drip: 900 mg in 500 ml D 5 W in glass container l 1. 8 mg/ml Use vented tubing for infusion

Diltiazem (Cardizem) l Dose – Bolus: 0. 25 mg/kg over 2 min l – l A-fib/A-flutter rate control Typical 10 -20 mg bolus Drip: 5 -15 mg/hr Mix – 125 mg in 100 ml D 5 W, LR, D 5 ½ NS l 1 mg/ml

Dobutamine (Dobutrex) l Dose – l Heart Failure 2 -20 mcg/kg/min Mix – 500 mg in 250 ml of NS, D 5 W, LR, D 5 ½ NS l 2000 mcg/ml

Dopamine (Intropin) l Dose – – – l Heart Failure/Renal Insufficiency Renal: 1 -3 mcg/kg/min Inotropic: 3 -10 mcg/kg/min Vasopressor: 10 -20 mcg/kg/min Mix – 400 mg in 250 ml of NS, D 5 W, LR, D 5 ½ NS l 1600 mcg/ml

Eptifibatide (Integrilin) l Dose – Bolus: 180 mcg/kg l – For PCI give 180 mcg/kg bolus 10 min after first Drip: l l l Platelet aggregation inhibitor Creatinine <2 mg/dl infuse at 2 mckg/kg/min Creatinine 2 -4 mg/dl infuse at 1 mcg/kg/min Mix – Infuse undiluted directly from 100 ml vial

Epinephrine (Adrenaline) l Dose – l 2 -10 mcg/min ACLS Dose – l Hypotension 1 mg IVP every 3 -5 min Mix – 4 mg in 250 ml D 5 W l 16 mcg/ml

Esmolol (Brevi. Bloc) l Dose – – l Bolus: 500 mcg/kg over 1 min Drip: 50 -200 mcg/kg/min ACLS dose – l Hypertension/a-fib, flutter rate control 500 mcg/kg over 1 min, then 4 min infusion at 50 mcg/kg/min. Max 4 min dose 200 mcg/kg Mix – 2. 5 GM in 250 ml NS, D 5 W, D 5 ½ NS l 10, 000 mcg/ml

Furosimide (Lasix) l Dose – l 1 -4 mg/min ACLS dose – l Acute pulmonary edema 0. 5 -2 mg/kg over 1 -2 min Mix – 200 mg in 100 ml D 5 W, NS, LR l 2 mg/ml

Heparin l Dose – – Bolus: 80 units/kg Drip: 18 units/kg/hr l l Anticoagulation Adjust as needed per protocol Mix – 10, 000 units in 250 ml D 5 W, NS l – 40 units/ml 10, 000 units in 100 ml for fluid restricted patient l 100 units/ml

Isoproterenol (Isuprel) l Dose – l 1 -10 mcg/min Mix – 1 mg in 250 ml D 5 W l 4 mcg/ml Bradycardia

Labetalol (Normodyne, Trandate) l Dose – l 2 -6 mg/min Mix – 500 mg in 150 ml D 5 W, LR l l Results in 250 ml of solution 2 mg/ml Hypertension

Lidocaine l Dose – l 1 -4 mg/min ACLS Dose – VF/VT l – 1 -1. 5 mg/kg repeat 5 to 10 min to max dose of 3 mg/kg Stable VT, wide complex tachycardia l l Anti arrhythmic 0. 5 -1. 5 mg/kg repeat 5 to 10 min to max dose of 3 mg/kg Mix – 1 GM in 250 ml NS, D 5 W l 4 mg/ml

Milrinone (Primacor) l Dose – – l Heart Failure Bolus: 50 mcg/kg over 10 min Drip: 0. 375 -0. 75 mcg/kg/min Mix – 50 mg in 250 ml D 5 W, NS, LR l – 200 mcg/ml 20 mg in 100 ml D 5 W, NS, LR l 200 mcg/ml

Nesiritide (Natrecor) l Dose – – l Acute decompensated heart failure Bolus: 2 mcg/kg over 1 min Drip: 0. 01 mcg/kg min Mix – 1. 5 mg in 250 ml D 5 W, NS, D 5 ¼ NS, D 5 ½ NS l 6 mcg/ml

Nicardipine (Cardene) l Dose – l Hypertension/Heart Failure 5 -15 mg/hr Mix – 25 mg in 250 ml D 5 W, NS, D 5 ½ NS l 0. 1 mg/ml

Nitroglycerin l Dose – 5 -200 mcg/min l l Angina/vasodilator Titrate to relief of chest pain Mix – 50 mg in 250 ml NS, D 5 W l l l 200 mcg/ml Mix in glass bottle only Use vented tubing

Norepinephrine (Levophed) l Dose – l 2 -30 mcg/min Mix – 4 mg in 250 ml D 5 W l 16 mcg/ml Hypotension

Phenylephrine (Neo-synephrine) l Dose – l 20 -80 mcg/min Mix – 20 mg in 250 ml D 5 W l – 80 mcg/ml 10 mg in 250 ml D 5 W l 40 mcg/ml Hypotension

Procainamide (Pronestyl) l Dose – l 1 -4 mg/min ACLS Dose – l Antiarrhythmic 20 -50 mg/min to total dose of 17 mg/kg Mix – 1 GM in 250 ml D 5 W, NS l 4 mg/ml

Sodium Nitroprusside (Nipride) l Dose – 0. 5 -10 mcg/kg/min l l Hypertension Titrate to desired effect every 3 -5 minutes Mix – 50 mg in 250 ml D 5 W, NS l l 200 mcg/ml Protect from light

Vassopressin (Pitressin) l Dose – – l Diabetes insipidus: 0. 0005 -0. 01 units/kg/hr GI Bleed: 0. 1 -0. 4 units/min ACLS Dose – l Diabetes insipidus, GI bleeding 40 units IVP to replace 1 st or 2 nd epinephrine dose Mix – D. insipidus: 20 units in 500 ml D 5 W l – 0. 04 units/ml GI Bleed: 20 units in 100 ml D 5 W l 0. 2 units/ml

ACLS Drugs Part 2 Not covered in infusion drugs

ACE Inhibitors l Enalapril – l Initially 5 mg, then to 10 mg daily after 48 hours Ramipril – l 6. 25 -50 mg tid as tolerated Lisinopril – l Initially 2. 5 mg, titrate as needed to 20 mg BID Captopril – l AMI afterload reducers/HTN 2. 5 -5 mg BID as tolerated Start within 24 hrs of onset for AMI, CHF w/LVEF <40%

Adenosine (Adenocard) l l l 6 mg rapid IVP followed by NS bolus of 20 ml Repeat w/12 mg after 1 -2 min if needed May repeat w/12 mg after 1 -2 min if needed l 2010 ACLS protocol does not include third dose – l PSVT conversion Recommends cardioversion if 12 mg dose not successful Converts PSVT to SR after brief period of asystole

Aspirin l Inhibits platelet aggregation Dose – – – 160 -325 mg Within minutes of onset of symptoms Chew and swallow non-enteric coated

Atropine l Dose – Bradycardia: 0. 5 mg every 3 -5 min l l Bradycardia Total dose 3 mg No longer recommended for asystole/slow PEA

Beta Blockers l Metoprolol – 5 mg IV q 5 min to 15 mg total l l 5 mg slow IV, repeat in 10 minutes l Convert to PO 50 mg BID Propranolol – 0. 1 mg/kg slow IVP in 3 doses at 2 min intervals l – l Convert to PO at 50 -100 mg daily Atenolol – l AMI to preserve LV function Max dose 1 mg/min Repeat in 2 min if necessary Carvedilol – – 3. 125 - 6. 25 mg PO after hemodynamically stable Target dose is 25 mg

Clopidogrel (Plavix) l ACS anti-platelet aggregation Initial dose 300 mg – Then 75 mg daily for 3 -9 months l At least 12 months with drug-eluting stent

Digoxin l Atrial fib/flutter: PSVT Dose – – Initial IV: 10 -15 mcg/kg of lean body weight Maintenance PO: 0. 125 -0. 5 mg daily

Flumazenil (Romazicon) l 1 st dose 0. 2 mg over 15 seconds – l If no adequate response give 3 rd dose in 1 min 3 rd dose 0. 5 mg over 30 seconds – l If no adequate response give 2 nd dose in 1 min 2 nd dose 0. 3 mg over 30 seconds – l Benzodiazopine antagonist If no adequate response may repeat every min Total dose 3 mg

Mannitol l Increased ICP Initial dose: 0. 5 -1 GM/kg over 5 -10 min Follow-up dose: 0. 25 -2 GM/kg every 4 -6 hr Use in-line filter for infusion

Naloxone Hcl (Narcan) l Dose – 0. 4 -2 mg l – l Opiate antagonist Repeat until response is adequate 6 -10 mg max over 10 min Monitor patient for return of opiate symptoms. Half life of naloxone is much less than half life of most opiates.

Verapamil (Calan) l 1 st dose – l l l 2. 5 -5 mg over 2 minutes 2 nd dose – l PSVT/Atrial fib/flutter 5 -10 mg May repeat every 15 to 30 min if needed Max dose 20 mg Contraindicated with Tikosyn