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PLACE LABEL HERE CORVERT (ibutilide) ATRIAL FIBRILLATION / FLUTTER PROTOCOL The following orders will be implemented per physician order of this protocol. Orders with a “” are indicator choices and are NOT implemented unless checked. 1. 2. 3. 4. Patient’s Actual Weight _________ kg Restricted to Cardiologists and Emergency Department (ED) Physicians Physician or assigned midlevel to be present during infusion. Restricted to ICU, IMCU, PCU, ED, ARU, 5N 5. Pre-Infusion Check List Nurse to confirm that all questions below are answered “yes”. If “No” answer, follow orders as indicated in the chart below. Corvert (ibutilide) may only be administered if all below questions are answered with a “Yes”: Yes Requirements Prior to Administration Is the Potassium (K) level > 4 within the past 24 hrs? Is the Magnesium (Mg) level > 2 within the past 24 hrs? Is 12-lead EKG in place and to be performed for baseline and during Corvert (ibutilide) infusion and cardiac monitoring for a minimum of 4 hrs after administration? Response if No: DO NOT ADMINISTER CORVERT (ibutilide) Draw stat potassium level If level < 4, call physician for replacement orders prior to administration of Corvert (ibutilide) and recheck potassium level 1 hr after replacement completed Draw stat magnesium level If level < 2, call physician for replacement orders prior to administration of Corvert (ibutilide) and recheck Mg level 1 hr after replacement completed Continuous cardiac monitoring for any arrhythmia activity or persistent QTc prolongation Is an ACLS certified nurse or physician present to monitor patient during and following Corvert (ibutilide) administration? Transfer patient to an appropriate unit described in #4 above Physician or midlevel documented baseline QTc by signing EKG and approved to administer Corvert (ibutilide). Have physician or midlevel monitor and document QTc on baseline EKG. Confirmed that patient is NOT currently or has previously taken any of the following medications: amiodarone, dronedarone, quinidine, procainamide, disopyramide, sotalol, dofetilide, flecainide or propafenone of other drugs known to prolong QT interval. If currently or previously taken a medication listed to the left, date last taken__________________ Physician was informed (Dr._________________, date/time________) and approved to administer. Notify physician if patient has converted and no longer in atrial fibrillation Is the patient still in atrial fibrillation immediately prior to administration of Corvert (ibutilide)? Copy to pharmacy *3-21578* FORM 3-21578 REV. 02/2016 Page 1 of 2 PLACE LABEL HERE CORVERT (ibutilide) ATRIAL FIBRILLATION / FLUTTER PROTOCOL The following orders will be implemented per physician order of this protocol. Orders with a “” are indicator choices and are NOT implemented unless checked. Corvert Dose and Administration: 6. Give Magnesium Sulfate 2 Gm IVPB over 10 minutes immediately prior to Corvert administration unless magnesium level > 3 or dialysis patient. 7. 12-lead EKG monitoring during infusion. 8. Corvert (ibutilide) Dosing: Patient’s weight >65 kg, give Corvert (ibutilide) 1 mg, slow IV push over 10 minutes Patient’s weight 60 kg - 65 kg, physician to evaluate and determine best dosing regimen: give Corvert (ibutilide) 1 mg, slow IV push over 10 minutes give Corvert (ibutilide) 0.01 mg/kg, slow IV push over 10 minutes Patient’s weight < 60 kg, give Corvert (ibutilide) 0.01 mg/kg, slow IV push over 10 minutes Corvert Infusion Monitoring Check List 9. Nurse to confirm that all questions below are answered “yes”. If “No” answer, follow orders as indicated in the chart below. Yes Requirements During and After Administration Check QTc interval at 5 minutes into Corvert (ibutilide) administration by a 12-lead EKG and copy in medical record. Is QTc < 500 ms at 5 minutes into infusion? Check QTc interval at the end of Corvert (ibutilide) administration by a 12-lead EKG and copy in medical record. Is QTc < 500 ms at end of infusion? The following medications are not currently ordered: amiodarone, dronedarone, quinidine, procainamide, disopyramide, sotalol, dofetilide, flecainide or propafenone within 4 hours post Corvert administration or other QT prolonging drugs. Response if No: DO NOT ADMINISTER CORVERT (ibutilide) If QTc > 500 ms, notify ordering physician immediately and stop Corvert (ibutilide) infusion If QTc > 500 ms, notify ordering physician immediately Confirm with physician. Risk may outweigh benefit by prolonging QTc interval and risk of torsade. 4 Hour Post- Infusion Monitoring 10. Continuous cardiac monitoring 4-hours post infusion. 11. Give additional Magnesium 2 Gm IVPB over 1 hour post infusion Corvert 12. Monitor for QTc prolongation > 500 ms, V-tach, new onset PVCs, or bradycardia < 50 bpm. Run a 12-lead EKG and call physician if any develop. 13. At end of 4 hours post infusion, run final 12-lead EKG and have physician review and document final rhythm. ______________ Date ________________ Time _________________________________ Physician Signature ___________ PID Number Copy to pharmacy FORM 3-21578 REV. 02/2016 Page 2 of 2