ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol

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1 ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Isoproterenol Major Indications Status Asthmaticus As a last resort for shock where there is vasoconstriction and low cardiac output after adequate fluid replacement According to the most recent ACLS guidelines, from 1995, isoproterenol is only recommended to treat bradycardia after atropine, dopamine, and epinephrine. (Please see comments.) Overdoses of beta blockers or calcium channel blockers Management of drug-induced "Torsades De Pointes" that is refractory to magnesium Mechanism of Action Isoproterenol is a beta-1 and beta-2 adrenergic receptor agonist. When given systemically, the drug stimulates beta receptors in the heart which produces positive inotropic and chronotropic effects and results in increased cardiac output. Stimulation of receptors in the smooth muscle of the bronchi produces bronchodilation. Isoproterenol shortens AV conduction time and refractory period in AV block. Pharmacokinetics Onset of Action: Peak Effects: Duration of Action: Immediate Within 15 mins Small Doses--8 mins Large Doses--up to 50 mins Monitoring Continuous EKG Continuous Blood Pressure Continuous Heart Rate Acid/Base Status Urinary Output Contraindications Pre-existing Tachyarrhythmias Tachycardia secondary to digitalis intoxication isoproterenol/page 1

2 Dosing and Administration **Isoproterenol must be administered as a dilute solution by constant IV infusion. IT MAY NOT BE GIVEN UNDILUTED AS A DIRECT IV BOLUS. Hemodynamically, significant bradycardia refractory to atropine in patients with a pulse. Isoproterenol is only indicated as a temporary measure until a pacemaker is available. Adults: 2-10mcg/min. by intravenous infusion titrated according to heat rate and rhythm response. See dosing charts. AV Block Shock Adults:Begin with 2 to 4 mcg/min. Suggested dosage range is 2-10 mcg/min. gradually titrated upward until a heart rate of approximately 60 beats/minute is reached. Adults:0.05 to 0.2 mcg/kg/min for patients in shock. Rates up to 30 mcg/min. have been used in advanced states of shock. Isoproterenol is only recommended when maximum doses of dobutamine have been ineffective and isoproterenol is added to dobutamine therapy. The dose should be titrated according to clinical response. *Some clinicians have recommended that isoproterenol be administered only for a short time (no longer than 1 hour) to patients with septic shock. Due to the side effects of vasodilatation and tachycardia, isoproterenol must be administered cautiously. Status Asthmaticus Adults: For control of bronchospasm unresponsive to inhalation therapy, mg IV (0.5-1 ml of a 1:50000 dilution*) is administered and repeated when necessary. Several cases of myocardial ischemia associated with isoproterenol have precluded its use as the beta-agonist of choice. * To prepare 1:50,000 dilution withdraw 1 ml from 1 mg (5ml) ampule of 1:5,000 concentration. Dilute the 1:5,000 isoproterenol with 9mls of normal saline for a resulting concentration of 1:50,000. Adverse Reactions 1. Cardiovascular effects include: sinus tachycardia, atrial tachycardia, PVC s, and ventricular tachycardia. Fatal ventricular arrhythmias have been seen when heart rates increased above 130 beats/minute. Due to increased oxygen demand may precipitate angina or coronary insufficiency, especially in patients with cardiogenic shock or ischemic heart disease. 2. May see a slight increase in blood pressure followed by a profound hypotension. 3. Central nervous system effects are: dizziness, faintness, headache, nervousness, tremor, and weakness. 4. Isolated reports of pulmonary edema have been noted. isoproterenol/page 2

3 Comments 1. The most recent ACLS guidelines, 1995, have reserved the use of isoproterenol in hemodynamically significant bradycardia due to its adverse effects. Currently, it is recommended only after atropine, dopamine, and epinephrine if a pacer is not available. Low dose isoproterenol is considered possibly helpful whereas high dose is considered harmful. 2. In pediatrics, the updated PALS guidelines do not recommend isoproterenol use in an arrest, the only indication is status asthmaticus. 3. Correct hypovolemia prior to the use of isoproterenol in shock. Fluid administration must be adequate to compensate for isoproterenol induced vasodilation or shock will be worsened. 4. Use caution in patients with diabetes, hyperthyroidism, angina, acute coronary syndromes, hypertension, hypovolemia, hypokalemia, hyperkalemia, or hypersensitivity to catecholamines. 5. Allow sufficient time to elapse before or after giving another beta-agonist to avoid additive effects (24 hrs.). 6. The combination of a beta-blocker and a nitrate will completely reverse the abnormal EKG findings induced by isoproterenol. isoproterenol/page 3

4 ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Pharmacy Department / Clinical Services IV Additive Service DRUG NAME (GENERIC) Isoproterenol Intravenous Infusion STORAGE REQUIREMENTS Isuprel Brand vials must be stored under refrigeration. Room temperature once mixed. PREPARATION Add the contents of 1 vial (1 mg per 5 ml) to a 250 ml bag of D5W or NSS. RESULTING CONCENTRATION STABILITY 4 mcg / ml - 24 hours after mixed and hung Synonyms (Trade Names): Generic Isoproterenol Brand Isuprel Notes: 1. Isoproterenol is incompatible with solutions containing sodium bicarbonate or other alkaline solutions. isoproterenol/page 4

5 Isoproterenol Continuous Infusion Dosing Chart 4 mcg/ml (1 mg per 250 ml) Concentration (prepared in the pharmacy) To Use Chart for mcg/kg/min rate: 1. Find weight on chart, in lbs. or kg., that is nearest to the patient's weight. 2. Drop down column to the first desired dose in mcg/kg/min. 3. To find a dose in mcg/min and flow rate, read across (to left) from the desired dose to Flow Rate ml/hr. Example: For a 78 kg. patient to be dosed at 0.05 mcg/kg/min, go to the weight column for 80 kg, drop down to the desired dose (1 st 0.05 mcg/kg/min.) and read to the left to get the required flow rate of 55 ml/hr. To Use Chart for mcg/min rate: 1. Find the desired rate in the 2 nd column from the left. 2. Look directly to the left in the 1 st column to find the rate in ml/hr. Example: To dose a patient at 2 mcg/min, the pump should be set for 30 ml/hr. Body Weight lbs kg Flow rate ml/hr Dose in mcg/min Dose in mcg/kg/min isoproterenol/page

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