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ANNE ARUNDEL MEDICAL CENTER
CRITICAL CARE MEDICATION MANUAL
DEPARTMENT OF NURSING AND PHARMACY
Guidelines for Use of Intravenous
Nesiritide (Natrecor®)
Major Indications
IV treatment of patients with acutely decompensated congestive heart failure who have dyspnea at rest or
with minimal activity.
Mechanism of Action
Nesiritide is a human recombinant form of B-type natriuretic peptide (BNP) that is identical to, and
mimics the actions of, endogenous BNP. Human BNP binds to (stimulates) the guanylate cyclase
receptor of vascular smooth muscle and endothelial cells, leading to increased intracellular concentrations
of guanosine 3', 5'-cyclic monophosphate (cGMP) and smooth muscle cell relaxation. Cyclic GMP
serves as a second messenger to dilate both veins and arteries. Nesiritide has natriuretic, diuretic,
vasodilatory, and smooth muscle relaxant activity. The drug has no pro-arrhythmic effects.
Monitoring
·
·
Blood pressure & heart rate should be monitored at 15 min., 30 min., 1 hr., 2 hrs., 3 hrs., 6 hrs., then
every 4 hours while on nesiritide
In patients with right heart catheters, hemodynamic measurements should be done and documented as
clinically indicated.
Pharmacokinetics
Onset of Action:
Peak effect:
Duration of Action:
Serum Half-life:
Nesiritide/page 1
11.2001 revised 9/2003
15 mins
Peak clinical effects are reached in approximately 3 hours; 60% of peak
effect is reached in 15 min and 95% is reached in 1 hour after starting the
infusion
2 hrs. Note: the effects of nesiritide do not dissipate rapidly as most
other vasoactive drugs, thus hypotension may persist for > 2 hrs. after
stopping the infusion.
18 minutes
Dosing, Adjustments, and Administration (see also incompatibility information under Comments)
Note: Nesiritide must be ordered via Physician Orders for Nesiritide Intravenous Infusion form
Initial Dose:
IV bolus of 2 micrograms/kg over 60 seconds followed by a continuous infusion at
a dose of 0.01 micrograms/kg/min. Note: the bolus dose (see dosing chart) is
never given from the reconstituted vial directly. Pharmacy will draw the
bolus dose up from the first infusion bag and provide it in a separate syringe.
Adjustments: For symptomatic hypotension, the dose should be held or reduced as other measure
to increase blood pressure are initiated (fluids, Trendelenberg). When SBP
stabilizes above 90 mmHg and/or symptoms resolve, the drug may be resumed
(without a bolus) at 30% less than the initial dose.
There is limited experience with doses above the standard recommended doses
above, however, for inadequate response, the dose may be increased at intervals
no less than every 3 hours. To increase, a 1 mcg/kg bolus may be given over 60
seconds followed by an increase of 0.005 mcg/kg/min. over the previous rate. If a
re-bolus is needed, please notify the pharmacy to have the bolus prepared for you.
The maximum rate of administration is 0.03 mcg/kg/min.
Always infuse nesiritide via an infusion pump device.
Never start nesiritide therapy at doses in excess of those recommended above.
Adverse Effects
Most common
Hypotension (11%)*
Headache (8%)
Back pain (4%)
Nausea (4%)
Elevated Creatinine > 0.5 over
baseline (28%)**
Less common
Ventricular tachycardia (3%)
Ventricular extrasystoles (3%)
Dizziness (3%)
Anxiety (3%)
Insomnia (2%)
Angina (2%)
Bradycardia (1%)
Abdominal pain (1%)
Vomiting (1%)
* Hypotension may last for 2 hours
** Risk for creatinine elevation is dose-related
Contraindications
1.
2.
Nesiritide is contraindicated in patients with know hypersensitivity to the drug.
According to the manufacturer, nesiritide should not be used in patients in cardiogenic shock,
patients with SBP <90 mmHg, or in patients with know, or suspected, low filling pressures.
Nesiritide has been used successfully in chronically hypotensive patients with SBP <90 mmHg
with careful selection of the bolus and initial infusion doses by the physician.
Nesiritide/page 2
11.2001 revised 9/2003
Comments
1.
2.
3.
Hypotension may be prolonged as long as 2 hours after stopping the infusion.
Risk of symptomatic hypotension is increased in patients using ACE inhibitor medications.
Incompatabilities:
a.
Nesiritide is incompatible with heparin and heparin-containing solutions AND
catheters. Do not mix or infuse nesiritide with heparin. Do not infuse nesiritide
into heparin impregnated IV catheters. Heparin may be co-administered as long as
it is via a separate catheter.
b.
Nesiritide is incompatible with metabisulfite preservatives. IV medications should
be checked for this preservative prior to mixing or co-administering with
nesiritide.
c.
Nesiritide is known to be incompatible with the following medications:
Heparin (as above)
Insulin
Ethacrynate (Edecrin)
Bumetanide (Bumex)
Enalaprilat (Vasotec)
Furosemide (Lasix)
Hydralazine
4.
Nesiritide may be administered via a peripheral IV or a centrally placed non-heparin coated
catheter.
Nesiritide/page 3
11.2001 revised 9/2003
ANNE ARUNDEL MEDICAL CENTER
CRITICAL CARE MEDICATION MANUAL
DEPARTMENT OF NURSING AND PHARMACY
Pharmacy Department / Clinical Services
IV Additive Service
DRUG NAME
(GENERIC
Nesiritide
Intravenous
Infusion
STORAGE
REQUIREMENTS
Room temperature or
refrigereated
1.
2.
3.
PREPARATION
Remove the 23 ml of overfill from
the 250 ml bag of D5W.
Add 5 ml of diluent (D5W or
NSS), drawn from a 250 ml
piggyback bag, to a 1.5 mg vial of
nesiritide.
2. Allow the nesiritide to dissolve
while rocking the vial gently to
ensure that all surfaces, including
the stopper, come in contact with
the diluent
RESULTING
CONCENTRATION
6 mcg/ml
STABILITY
24 hours
(DO NOT SHAKE)
4.
Add the dissolved nesiritide into
the 250 ml piggyback bag. Invert
the bag several times to ensure
mixing of the drug.
Synonyms (Trade Names):
Natrecor (manufactured by SCIOS, Inc.)
Notes:
The diluted solution is used by the pharmacy to draw up the bolus dose for nursing. Never administer nesiritide
directly from the vial.
Nesiritide/page 4
11.2001 revised 9/2003
ANNE ARUNDEL MEDICAL CENTER
CRITICAL CARE MEDICATION MANUAL
DEPARTMENT OF NURSING AND PHARMACY
Nesiritide (6 mcg / ml) Dosing Chart
The following chart allows quick determination of the amount and rate for bolus and maintenance doses,
respectively, of nesiritide 6 mcg/ml infusion concentration. Never administer nesiritide directly from the vial.
Doses, in ml., for this concentration may also easily be calculated by:
Bolus Volume (in ml of 6 mcg/ml concenmtration) = 0.33 X Patient Weight (in KG)
Maintenance Rate (in ml/hr of the 6 mcg/ml concentration) = 0.1 X Patient Weight (in KG)
To Use Chart:
1.
Find the weight (in kg) closest to the patients weight in the far left column
2.
Read over to the next column to determine the amount of bolus, in mcg, to achieve a 2 mcg/kg dose.
3.
Read over to the third column to determine the amount, in ml., of 6 mcg/ml solution to administer
over 60 seconds to achieve a 2 mcg/kg dose
4.
Read over, from the patients weight, to the far right column to find the rate to set an infusion pump
(in ml/hr) to deliver a 0.01 mcg/kg/min maintenance dose
Patient Weight (in
KG)
Amount of Bolus Dose
in mcg (for 2 mcg/kg)
Volume of Bolus (in ml
of 6 mcg / ml
concentration)
Rate of Maintenance
Infusion (in ml/hr of
6 mcg / ml concentration)
50
100
16.7
5
55
110
18.3
5.5
60
120
20
6
65
130
21.7
6.5
70
140
23.3
7
75
150
25
7.5
80
160
26.7
8
85
170
28.3
8.5
90
180
30
9
95
190
31.7
9.5
100
200
33.3
10
105
210
35
10.5
110
220
36.7
11
115
230
38.3
11.5
120
240
40
12
125
250
41.7
12.5
130
260
43.3
13.0
Nesiritide/page 5
11.2001 revised 9/2003
Anne Arundel Medical Center
Annapolis, MD 21401
Physicians Orders
I hereby authorize the pharmacy to dispense a generic equivalent unless the particular drug is circled.
Physician Orders for Nesiritide (Natrecor) Intravenous Infusion
Check boxes as appropriate
Date Time Time
Ord. Ord. Noted
1. Indication:_____________________________________
2. Patient’s weight: __________ kg. (required)
3. Labs prior to initiation:
¨ Baseline BNP
¨ Baseline and daily Basic Metabolic Panel
4.
Bolus IV Dose (check one):
q 2 mcg/kg over 60 seconds
q other: _________ mcg/kg over 60 seconds
q none
5. Maintenance IV Infusion for ___________ hrs.
q 0.01 mcg/kg/min.
q other: _________ mcg/kg/min.
6. Monitoring:
¨ Blood pressure and heart rate as per Nesiritide Critical
Care Medication Manual Guidelines At 15 min., 30 min., 1 hr., 2 hrs., 3 hrs., 6 hrs., then every 4 hours while on
nesiritide.
¨ Baseline and daily weights.
¨ Strict In's and Out's.
7. Notify physician on call for (check one):
q SBP < 90 mmHg
q SBP < ____ mmHg
.
Signature of Prescriber
Nesiritide/page 6
11.2001 revised 9/2003