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
ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Ibutilide (Corvert®) Indication For rapid conversion of atrial fibrillation or atrial flutter of recent onset to sinus rhythm when DC cardioversion is not preferred. Mechanism of Action Ibutilide is an antiarrhythmic drug with predominantly class III properties. Ibutilide prolongs atrial and ventricular action potential duration and refractoriness via delay of repolarization by action of a slow inward current (predominantly sodium) in comparison to most other class III antiarrhythmics. Special Administration and Monitoring Techniques · · · · · · · · · Ibutilide may be pro-arrhythmic and can cause fatal arrhythmias (see Comments). Use of ibutilide on the A3 and IMU patient areas requires attachment of a “hands-off” defibrillator prior to drug administration. Anticoagulation should be considered prior to ibutilide in patients with atrial fibrillation of greater than 2 days’ duration. Electrolytes: · Serum potassium should be measured prior to ibutilide administration; potassium supplementation (to 4.0 mm/L) should be considered for all patients with baseline serum potassium < 4.0 mm/L. · Intravenous magnesium should be given (MgSO4 2 grams in 100 cc D5W IV over 30 minutes) prior to ibutilide infusion in all patients except when baseline magnesium may be already elevated (e.g. serum creatinine > 2.0 mg/dl). Ibutilide is administered intravenously. An initial infusion is given over 10 minutes followed by a second 10-minute infusion if the arrhythmia is not terminated within 10 minutes after the end of the initial infusion. Ibutilide should be stopped if the arrhythmia is terminated during the infusion / dose. Monitoring EKG, blood pressure, and pulse is indicated for any patient receiving ibutilide. Continuous EKG monitoring is indicated for at least 4 hours following infusion, or until the QTc interval returns to baseline. EKG monitoring for longer periods is advised in patients with liver dysfunction or if pro-arrhythmic activity is observed. Dosage adjustment is not necessary with renal or hepatic disease. Dosage adjustment is not indicated in older individuals. Ibutilide reviewed 11/02 Dosage and Administration Intravenous doses of ibutilide should be infused over a period of 10 minutes. The drug can be given undiluted or diluted in 50 ml 5% dextrose or normal saline. If dilution preferred, the contents of one 10 ml vial (1 mg / 10 ml) is added to a 50 ml infusion bag to form a final concentration of approximately 0.017 mg/ml (1 mg / 60 ml). The recommended dose is 1 mg IV for patients weighing > 60 kg (132 pounds). For patients weighing less than 60 kg, a dose of 0.01 mg/kg should be administered. A second equal dose may be given 10 minutes after the completion of the first infusion (20 minutes from the beginning of the first infusion) if the arrhythmia is not terminated. Recommended Dose of Ibutilide (CORVERT®) Injection Patient Weight 60 kg (132 LB) or more <60 kg (<132 LB) Initial Infusion (over 10 minutes) One Vial – 10 ml (1 mg ibutilide fumarate) 0.1ml/kg (0.01 mg/kg ibutilide fumarate) Second Infusion (over 10 minutes) If the arrhythmia does not terminate within 10 minutes after the end of the initial infusion, a second 10-minute infusion of equal strength may be administered 10 minutes after the completion of the first infusion. Precautions 1. Ibutilide is not recommended in patients with a history of polymorphic v-tach. 2. Class IA antiarrhythmic drugs, such as disopyramide, quinidine, and procainamide, and other class III drugs, such as amiodarone and sotalolol, may increase the risk of proarrhythmic effects. This risk should be considered by the ordering physician. Options include monitoring closely for prolong refractoriness and/or holding the other antiarrhythmic for 5 half-lives prior to ibutilide and within 4 hours post-infusion . 3. The potential for pro-arrhythmia may increase with the administration of ibutilide to patients who are concomitantly receiving other drugs that can prolong the QT interval, such as phenothiazines, tricyclic antidepressants, and certain antihistamine drugs (H1 receptor antagonists), specifically terfenadine (Seldane) and astemizole (Hismanal). 4. Safety and efficacy in patients < 18 years old is unknown. Adverse Effects Cardiovascular – ventricular extrasystoles, non-sustained monomorphic VT, non-sustained polymorphic VT, hypotension, bundle branch block, sustained polymorphic VT, AV block, hypertension, QT segment prolongation, bradycardia, palpitations, and tachycardia. Prolongation of the QTc interval has correlated directly with plasma levels. The greatest prolongation has been seen at the end of an infusion and the QTc interval returns to baseline 2 to 4 hours after completion of the infusion. Polymorphic VT (PVT) has coincided with maximal ibutilide levels (and maximum changes in the QTc interval), and the PVT is usually seen within 40 minutes of the start of an infusion. However, plasma levels at the time of PVT occurrence in patients developing this arrhythmia have been similar to levels in patients not developing PVT, and there is no threshold concentration at which the risk of its occurrence would be significantly higher. Gastrointestinal – nausea Central Nervous System - headache Ibutilide reviewed 11/02 Comments Ibutilide can cause potentially fatal arrhythmias, particularly sustained polymorphic ventricular tachycardia, usually in association with QT prolongation (torsades de pointes), but sometimes without documented QT prolongation. It is essential that ibutilide be administered in the setting of continuous EKG monitoring and by personnel trained in the identification and treatment of acute ventricular arrhythmias, particularly polymorphic VT. Most cases of polymorphic VT respond to overdrive pacing and intravenous magnesium infusion, however degeneration to VF requiring defibrillation may occur. Ibutilide reviewed 11/02 Pharmacy Department/Clinical Services IV Additive Service DRUG NAME STORAGE REQUIREMENTS PREPARATION Ibutilide piggyback Room temperature Add 10 ml (one 1 mg / 10 ml vial) ibutilide to 50 ml of D5W or NSS RESULTING CONCENTRATION 0.017 mg/ml (1 mg / 60 ml) Synonyms (Trade Names): Corvert® Notes: 1. 2. 3. Ibutilide may also be given undiluted IV push over 10 minutes. Ibutilide should only be mixed with D5W or NSS. Stable for 24 hours at room temperature and 48 hours at refrigerated temperatures. Ibutilide reviewed 11/02 STABILITY 24 hrs