Cardiac Infusions

1
Cardiac Infusions

• Peter Mirehouse RN, PNII
• Ginny Coleman RN, BSN, PNIII
• Robert Masterson RN, BSN, CCRN, PNIII

Integrilin
Nitroglycerin
Amiodarone
2
Amiodarone

• Robert Masterson RN, BSN,CCRN
• PNIII

3
FDA Labeled Indications

• MANAGEMENT OF LIFE-THREATENUNG RECURRENT Vf /
  UNSTABLE VT
• IV.ACUTE Vf /UNSTABLE VT
• OFF-LABEL CONVERSION OF Af TO NSR STABLE VT

4
Clinical Uses

• CARDIAC ARRESTANTI-ARRHYTHMIC OF CHOICE IN Vf/VT
  ARREST
• MANAGEMENT OF SERIOUS ARRHYTHMIAS WHEN OTHER
  TREATMENTS HAVE FAILED

5
Drug class

• AMIODARONE IS A CLASS III ANTI-ARRHYTHMIC BUT
  SHARES PROPERTIES OF CLASSES I-IV
  ANTI-ARRHYTHMICS
• HIGHLY EFFECTIVE WITH LOW PRO-ARRHYTHMIC RISK

6
Mechanism of Action

• VAUGHAN WILLIAMS CLASSIFICATION ENTAILS 4 CLASSES
  REFLECTING 4 ACTIONS, i.e. SODIUM,BETA
  ADRENERGIC,POTASSIUM AND CALCIUM BLOCKADE
• CLASS III DRUGS PROLONGS REPOLARIZATION AND
  REFRACTORY PERIOD THEREBY PREVENTING RE-ENTRY
  ARRTHYMIAS

7
Pharmacokinetics

• Distribution, Metabolism, Excretion, Elimination
  and Half Life
• AMIODARONE REQUIRED A LOADING DOSE
• ORALLY,LOADING TAKES 1-2 WEEKS TO REACH
  THERAPEUTIC SERUM LEVELS
• IV LOADING DOSE CONSISTS OF 150MG OVER 10, THEN
  360 MG OVER NEXT 6 HOURS THEN 540 MG OVER NEXT 18
  HOURS (TOTAL 1000MG IN FIRST 24 HOURS

8
Pharmacokinetics

• BEFORE AMIODARONE BECOMES EFFECTIVE, IT MUST
  SATURATE ALL TISSUES OF THE BODY
• HALF-LIFE OF AMODARONE IS EXTREMELY LONG 1 YEAR
  AFTER DISCONTINUATION, MEASURABLE SERUM LEVELS
  OBTAINABLE
• NUMEROUS DRUG-DRUG INTERACTIONS ARE KNOWN

9
Contraindications of use
1.PREGNANCY/LACTATION 2.CARDIOGENIC
SHOCK 3.BRADYCARDIA 4.SINUS NODE
DYSFUNCTION 5.THYROID DX 6.LUNG DX
10
Precautions of use

• PATIENT MUST BE FULLY INFORMED OF RISKS AND HAVE
  GIVEN THEIR CONSENT BEFORE USE IF POSSIBLE
• 2. OPTIMIZE ELECTROLYTES (POTASSIUM/MAGNESIUM)
  PRIOR TO INITIATING TX

11
Potential side effects

• SIDE EFFECTS ARE MANY AND POTENTIALLY SEVERE
• 25-30 OF PATIENTS DEVELOP 1 OR MORE SIDE-EFFECTS
  SUCH AS
• ARDS (2),PULMONARY FIBROSIS,THYROID DXS, LIVER
  /KIDNEY FAILURE, SEVERE ATAXIA,HALO
  VISION,PERMANENT BLINDNESS, PERIPH.NEUROPATHY,
  SMURF SYNDROME, SUN SENSITIVITY, POOR SLEEP, POOR
  CONCENTRATION, TORSADES, AND MANY MORE MILDER
  SIDE EFFECTS

12
Mercys protocol for administration

• CODE BLUE3 AMPS OF AMIODARONE 150MG IN EACH CODE
  CART-DOSAGE IN Vf/VT 300 mg IV/IO PUSHMAY
  REPEAT 150 MG IV/IO PUSH
• STABLE VT DOSAGE 150 MG /100 D5W OVER 10
• MIX IN D5W-ALL INFUSIONS LASTING LONGER THAN 2
  HOURS SHOULD BE IN GLASS W/A FILTER
• CENTRAL LINE PREFERRED

13
Monitoring

• PATIENT MUST HAVE CARDIAC MONITORING FOR ALL
  AMIODARONE LOADING
• GREATEST ACUTE RISK IS HYPOTENSION WHICH MAY BE
  TREATED W/ RATE REDUCTION ,VASOPRESSORS,INOTROPES,
  AND VOLUME. 2 OF HYPOTENSIVE PATIENTS REQUIRE
  DISCONTINUATION OF THERAPY

14
Toxicology

• AMIODARONES LIVER,LUNG,THYROID,EYE, SKIN AND
  NERVE TOXICITIES REQUIRE INTENSIVE MONITORING
• ADVERSE EFFECTS TAKE WEEKS TO MONTHS TO DEVELOP
  AND MAY BE INSIDIOUS
• ANTI-ARRHYTHMICS SHOULB BE USED ON
  TRIAL-AND-ERROR BASIS.ONCE YOU ARE ON AMIODARONE,
  YOURE ON IT FOR LIFE!

15
Patient teaching

• PATIENTS MUST BE FULLY IMFORMED OF RISKS AND
  BENEFITS OF AMIODARONE AND BE PREPARED TO FOLLOW
  THROUGH WITH NECESSARY MONITORING.
• ALL NEW MEDICATIONS/SUPPLEMENTS MUST BE CLEARED
  BY THEIR PHYSICIAN AND PHARMACIST
• PATIENT MUST APPRECIATE THE IMPORTANCE OF PROMPT
  REPORTING OF ALL NEW SIGNS/SYMPTOMS

16
REVIEW

• AMIODARONE IS HIGHLY EFFECTIVE ANTI-ARRHYTHMIC
  WITH A LOW RISK OF PRO-ARRHYTHMIA(SUDDEN DEATH)
• BIZARRE TOXIC PROFILE

17
Nitroglycerin

• Peter Mirehouse RN, PNII

18
FDA labeled indications
19
FDA Labeled Indications

• Angina
• Not responsive to sublingual nitroglycerin
• Congestive Heart failure - MI

20
Clinical Uses

• Treatment or prevention of Angina Pectoris
• Acute decompensated heart failure (especially
  associated with myocardial infarction)
• Short-term management of pulmonary hypertension
  (unlabeled/Investigational)

21
Drug class

• Nitrate

22
Mechanism of Action

• Produces a vasodilator effect to peripheral veins
  and arteries.
• Primarily reduces cardiac oxygen demand by
  decreasing preload, and modestly reduce
  afterload.
• Dilates coronary arteries and increases
  collateral flow to ischemic regions.

23
Pharmacokinetics

• Distribution, Metabolism, Excretion, Elimination
  and Half Life

24
Pharmacokinetics

• Onset of action Immediate
• Peak effect Immediate
• Duration 3-5 minutes
• Metabolism in liver and excreted in urine.

25
Contraindications

• Hypersensitivity to organic nitrates.
• Increase cranial pressure.
• Severe anemia
• Constrictive pericarditis
• Pericardial tamponade
• Restrictive cardiomyopathy
• Concomitant use of phosphodiesterase type -5
  (Viagra)

26
Precautions of use

• Hypotension (SBP lt90 mm hg or 30 mm hg below
  baseline)
• Extreme bradycardia (lt 50 bpm)
• Tachycardia without heart failure (100 bpm)
• Right Ventricular infarct

27
Potential side effects

• Cardiovascular flushing, hypotension, peripheral
  edema, postural hypotension, syncope, tachycardia
• Central Nervous headache (common), dizziness,
  lightheadedness
• Gastrointestinal Nausea, vomiting, xerostomia
• Respiratory Dyspnea, pharngitis, rhinitis

28
Administration/Dosing

• IV Nitroglycerin comes in premixed bottles
• 50mg Nitroglycerin in 250ml D5W
• 200mcg/ml
• Must use Nitroglycerin tubing
• 5 mcg/min, increase by 5 mcg/min every 3-5
  minutes to 20mcg/min. If no response at 20
  mcg/min, may increase by 10 to 20 mcg/min every
  3-5 minutes.
• Generally accepted maximum dose is 400mcg/min

29
Monitoring

• Blood pressure
• Heart rate

30
Toxicology

• Clinical effects, treatment and range of
  toxicology

Toxicity has not been established in adults or
children
31
Patient teaching

• Report any signs and symptoms
• headache, dizziness, lightheadedness, nausea,
  vomiting.

32
Integrilin

• Ginny Coleman RN, BSN, PNIII

33
FDA labeled indications
34
FDA Labeled Indications

• Acute coronary syndrome
• Percutaneous coronary intervention

35
Clinical uses
36
Clinical Uses

• Used for anticoagulation in patients with acute
  coronary syndrome or undergoing percutaneous
  coronary intervention
• May be used concurrently with IV Heparin, low
  molecular weight heparin and po Aspirin

37
Drug class

• Glycoprotein IIb IIIa receptor antagonists

38
Mechanism of action
39
Mechanism of Action

• Inhibits platelet aggregation
• Reversibly binds to the platelet receptor
  glycoprotein IIb/IIIa of human platelets
• Prevents the binding of fibrinogen, von
  Willebrand factor and other adhesive ligands to
  inhibit blood clot formation

40
Platelet aggregation
41
Pharmacokinetics

• Distribution, Metabolism, Excretion, Elimination
  and Half Life

42
Pharmacokinetics

• Distribution Human plasma protein binding
  25 Volume distribution of 0.2L/kg
• Steady state of medication achieved within 4-6
  hours
• Excretion Renal 50 to 71.4, hemodialysis
  yes 73 to 83
• Elimination Half-life 1.13 to 2.5 hours

43
Contraindications of use
44
Contraindications of use

• Abnormal bleeding, either active or within the
  previous 30 days
• Administration of other parenteral glycoprotein
  IIb/IIIa inhibitors, current or planned (ReoPro
  or Aggrastat)
• Hypersensitivity to Integrilin
• Uncontrolled severe hypertension (SBP gt 200 mmHg
  or DBP gt 110)
• Major surgery within previous 6 weeks
• Renal dialysis
• Stroke within previous 30 days
• Any history of hemmorhagic stroke

45
Precautions of use
46
Precautions of use

• Arterial sheath removal ensure PTT is lt 45
  seconds, recommend heparin d/c 3-4 hours prior
• Major or minor bleeding
• Non-compressable IV sites (subclavian or jugular
  vein)
• Platelet count lt 100,000 mm recommend
  monitoring
• Renal insufficiency adjust dosing
• Vascular or other trauma minimize arterial and
  venous punctures, IM injections, nasogastric
  tubes, nasotracheal intubation or urinary
  catheters

47
Potential side effects
48
Potential side effects

• Bleeding, may be major or minor
• Cerebral hemmorhage
• Intracranial hemmorhage
• Pulmonary hemmorhage
• Hypotension
• Anaphylaxis
• Thrombocytopenia

49
Mercys protocol for administration
50
Mercys protocol for administration

• Integrilin is administered based on patient
  weight
• Initial bolus to be given which is based on
  patient weight (180 mcg/kg)
• Second bolus (180 mcg/kg) administered 10 minutes
  after first bolus for percutaneous coronary
  intervention ONLY
• Infusion rate (which must follow first bolus for
  both PCI and ACS) for creatinine lt 2 mg/dL 2
  mcg/kg/minute
• Infusion rate for creatinine 2-4 mg/dL 1
  mcg/kg/minute

51
Monitoring
52
Monitoring

• Obtain prothrombin time (PT) and/or activated
  partial thromboplastin time (aPTT) prior to
  initiation of therapy
• aPTT during therapy to maintain a target aPTT
  between 50 and 70 seconds, unless percutaneous
  coronary intervention is to be performed
• Activated clotting time (ACT) during PCI to
  target of 200 to 300 seconds
• aPTT or ACT prior to arterial sheath removal

53
Toxicology

• Clinical effects, treatment and range of
  toxicology

54
Toxicology

• Clinical effects of toxicity bleeding,
  thrombocytopenia, hypotension, anaphylaxis,
  neurological or pulmonary changes
• Treatments discontinue therapy platelet
  transfusion if count is lt 20,000 vasopressive
  medications for hypotension antihistamines and
  epinephrine, IVF for anaphylaxis
• Monitor CBC, aPTT, INR

55
Patient teaching
56
Patient teaching

• Educate patient it may take longer to stop
  bleeding during and after drug infusion.
  Pressure needs to be applied to bleeding sites
• Bed rest may be required during and several hours
  post infusion
• Educate patient to avoid cuts and bruising for up
  to 3 days post infusion
• Educate patient to report signs and symptoms of
  bleeding or hypotension

57
Case STudy
58
Case study

• 54-year-old female with history of HTN,
  hyperlipidemia, obesity and tobacco use
• Presents to ER with complaints of exertional
  upper sub-sternal chest pain relieved with IV
  morphine, nitrates and heparin in the ER
• Peak troponin I of 6.17
• No EKG changes
• Cardiology consulted and placed patient on IV
  Heparin, po ASA, beta blockers, po statin, IV
  Nitroglycerin gtt titrate to chest pain and IV
  Integrilin at 2 mcg/kg/minute

59
Case Study medication calculation

• Integrilin gtt ordered at 2 mcg/kg/minute
• Patient is 122 kg
• 2mcg x 122 kg x 60 minutes 14640 mcg/hr
• Infusion contains Integrilin 75 mg/100 mL
• Concentration 0.75 mg/mL
• Concentration 750 mcg/mL (0.75mg x 1000 mcg)
• 14640 mcg/hr / 750 mcg/hr 19.5 mL/hr

60
IV Medication Titration Intervention
61
IV Medication Titration Intervention
62
Complete with each rate change. Minimum of
once a shift.
63
Case study

• Patient underwent cardiac catheterization
  results normal EF, left coronary artery - no
  obstruction, right coronary artery - greater than
  90 focal obstruction mid-vessel with slow
  distal flow
• Patient transferred to MMC with sheath left in
  place for intervention on her right coronary
  artery

64
References

• Curran, M.P. Keating, G.M. (2005).
  Eptifibatide A Review of its Use in Patients
  with Acute Coronary Syndrome and/or Undergoing
  Percutaneous Coronary Intervention. Drugs2005.
  65(14), 2009-2035. Retrieved from CINAHL.
• Micromedex 2.0. (2012). Eptifibatide. Retrieved
  from http//www.thomsonhc.com/micromedex2/libraria
  n/ND_T/evidencexpert/ND_PR/evidencexpert/CS/4F2B70
  /ND_AppProduct/evidencexpert/DUPLICATIONSHIELDSYNC
  /ED70C0/ND_PG/evidencexpert/ND_B/evidencexpert/ND_
  P/evidencexpert/PFActionId/evidencexpert.DoIntegra
  tedSearch?SearchTermintegrilin