Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Liverpool Hospital Drug Guideline ICU: Pharmacology Verapamil Intensive Care Unit Verapamil Summary: Verapamil is a calcium ion influx inhibitor which can be used to lower raised blood pressure and as an antiarrhythmic for supraventricular tachycardia. Approved by: ICU Medical Director Publication (Issue) Date: April 2013 Next Review Date: April 2016 Replaces Existing Drug Guideline: June 2007 Previous Review Dates: November 2003 1. Introduction:: Patient safety The Aims / Expected Outcome of this drug guideline: Verapamil will be administered safely and appropriately without any adverse side effects • • • Related Policies C3.00 Drug prescribing C3.01 Drug administration C3.01 Administration of IV Medications 2. Drug Guideline: Policy Statement • All care provided within Liverpool Hospital will be in accordance with infection control, manual handling and minimisation and management of aggression guidelines. • Medications are to be prescribed and signed by a medical officer/authorised nurse practitioner (NP) unless required during an emergency. • All drugs administered during an emergency (under the direction of a medical officer/authorised nurse practitioner) are to be documented during the event, then prescribed and signed following the event. • Medications are to be given at the time prescribed (as close to the time as is possible when multiple drugs require ‘same time’ administration and, when the nurse is caring for more than one patient, recognition is given to a possible short delay to administration – antibiotics and other lifesaving drugs are to be prioritised) and are to be signed by the administering nurse. • Parenteral medication prescriptions and the drug are to be checked with a second registered or endorsed enrolled nurse prior to administration. The “rights of drug administration” must be followed: right: patient, drug, dose, route, administration, time, reason for the drug, documentation, education and evaluation/outcome. LH_ICU2013_Pharmacology_verapamil Page 1 of 4 Liverpool Hospital • • • 3. ICU: Pharmacology Verapamil Intensive Care Unit Adverse drug reactions are to be documented and reported to a medical officer. Medication errors are to be reported using the hospital electronic reporting system: IIMS. Guidelines are for adult patients unless otherwise stated Guideline Actions Verapamil is a calcium channel blocker affecting vascular smooth muscle, myocardial contractility and cardiac conduction via the A-V node. It acts by inhibiting calcium ion influx across the cell membrane of the arterial smooth muscle as well as in conductile and contractile myocardial cells. It prolongs impulse conduction in the atrioventricular node and thus depending on the type of arrhythmia, restores the sinus rhythm and normalises the ventricular rate. It reduces myocardial oxygen consumption directly by intervening in energy consuming metabolic processes of the myocardial cell (reducing heart rate and contractility) and indirectly by diminishing the peripheral resistance (afterload). The decrease of vascular smooth muscle tone prevents coronary spasms and lowers raised blood pressure. Indications. • Supraventricular Tachycardia. • Acute Hypertension • Management of vasospasm associated with artery grafts used in coronary bypass surgery. Contraindications • Hypersensitivity. • Wide QRS tachycardia (where there is any doubt as to whether the rhythm is VT or SVT with aberrant conduction). • Complicated acute myocardial infarction (bradycardia, hypotension, left ventricular failure) • Ventricular dysrhythmias. • Concomitant use with beta-blockers: may cause heart block and asystole. • Hypotension. • Pulse rate < 50. nd rd • Any evidence of 2 or 3 degree heart block. • Patients with AF or AF with Wolff-Parkinson-White syndrome, these patients are at risk of ventricular tachycardia or ventricular fibrillation if verapamil is administered. Precautions • Severe hypotension can occur with rapid administration. It should be given as slow IV injection and promptly discontinued if severe hypotension occurs. • As it slows conduction via the AV node it can lead to second or third degree AV block (especially in patients with sick sinus syndrome). • Use with caution in patients with hepatic failure, because the effect is intensified and prolonged depending on the disease severity. • In patients with renal disease - observe for abnormally prolonged PR intervals, indicating excessive effect. • Should not be used in the first and second trimester of pregnancy and only later with regard to maternal hypotension and foetal hypoxia. LH_ICU2013_Pharmacology_verapamil Page 2 of 4 Liverpool Hospital ICU: Pharmacology Verapamil Intensive Care Unit Significant interactions Beta-Blockers - increased risk of bradyarryhmias, heart block and asystole, especially in patients with cardiomyopathy, congestive heart failure or recent myocardial infarction. Antihypertensives, diuretics, vasodilators potentiate the hypertensive effects. Digoxin, cyclosporin - increases the plasma levels of these drugs. Carbemazepine – it potentiates the effect and enhances risk of neurotoxicity Non-depolarising muscle relaxants – there is a risk of prolonged action when they are administered with verapamil. Lithium – increased sensitivity to the effects of lithium with risk of neurotoxicity. Quinidine, amiodarone, procainamide, flecainide, disopyramide - increased risk of heart failure, bradycardia, and proarrhythmic effect. Adverse effects • Hypotension. • Bradycardia and first or second degree AV block. • Headache, dizziness, flushing, nausea. Presentation Verapamil 5mg in 2mL ampoule. Administrations Guidelines Management of supraventricular tachycardia: • Dilute 5mg verapamil in 10mL sterile 0.9% sodium chloride (0.5mg/mL). • Administer verapamil 1mg/minute IV slow bolus until heart rate slows, may be repeated once in the next in five to ten minutes for tachyarrhythmias and hypertension. Post radial artery graft and bilateral internal mammary artery graft used in coronary bypass surgery: Dilute verapamil 10mg in 50mL sterile 0.9% sodium chloride (to give a concentratio = 0.2mg/ml). Infuse at a rate of 0.2micrograms/kg/minute Example for patient weighing 70kg = 14micrograms /min = 840micrograms /hour = 0.84mg/hour = 4.2mL/hr. Continue infusion postoperatively until the morning of Day 1. Administer Diltiazem orally. Use Diltiazem 30mg tds if SBP < 120mmHg OR Diltiazem CD 180mg once daily if SBP ≥ 120mmHg. Use clinical judgement to decide which is the most appropriate dose. 4 hours post oral diltiazem, cease verapamil infusion. Clinical Considerations ECG and blood pressure monitoring is necessary for patients receiving intravenous verapamil. Severe hypotension as a result of administration should be treated with vasoconstrictors. Second or third AV block if it occurs should be treated with atropine, isoprenaline or external pacing. 4. Performance Measures All incidents are documented using the hospital electronic reporting system: IIMS and managed appropriately by the NUM and staff as directed. LH_ICU2013_Pharmacology_verapamil Page 3 of 4 Liverpool Hospital ICU: Pharmacology Verapamil Intensive Care Unit 5. References / Links 1. MIMS Online, CIAP: NSW Health Department, Copyright MIMS Australia Pty Ltd. February 2012. http://www.use.hcn.com.au 2. The Society of Hospital Pharmacists of Australia 2007, The Australian Injectable Drugs th Handbook, 4 Edition, SHPA publications, Australia. 3. eTherapeutic Guidelines: CIAP 2012, http://www.tg.org.au/ th 4. Thomas Reuters, Micromedex 2.0, http://www.micromedex.com/, viewed 13 March 2012. Author: Reviewers: CNC (S.Shunker) ICU Director, ICU – NM, NUM, ICU – CNE, ICU – CNS, Pharmacist. Endorsed by: A Proff Michael Parr, ICU Director LH_ICU2013_Pharmacology_verapamil Page 4 of 4