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1 High Alert Adverse Reactions/Side Effects

CNS: fatigue, agitation, confusion, dizziness, drowsiness, weakness. CV: hypoten- PDF Page #1
esmolol (es-moe-lole) sion, peripheral ischemia. GI: nausea, vomiting. Derm: sweating. Local: injection
Brevibloc site reactions.
Classification Interactions
Therapeutic: antiarrhythmics (class II) Drug-Drug: General anesthesia, IV phenytoin, and verapamil may cause ad-
Pharmacologic: beta blockers ditive myocardial depression. Additive bradycardia may occur with digoxin. Additive
Pregnancy Category C hypotension may occur with other antihypertensives, acute ingestion of alcohol,
or nitrates. Concurrent use with amphetamine, cocaine, ephedrine, epineph-
rine, norepinephrine, phenylephrine, or pseudoephedrine may result in un-
Indications opposed alpha-adrenergic stimulation (excessive hypertension, bradycardia). Con-
Management of sinus tachycardia and supraventricular arrhythmias. current thyroid hormone administration may p effectiveness. May alter the
effectiveness of insulins or oral hypoglycemic agents (dose adjustments may be
Action necessary). Maypeffectiveness of theophylline. Maypbeneficial beta cardiovascu-
Blocks stimulation of beta1(myocardial)-adrenergic receptors. Does not usually af- lar effects of dopamine or dobutamine. Use cautiously within 14 days of MAO in-
fect beta2(pulmonary, vascular, or uterine)-receptor sites. Therapeutic Effects: hibitor therapy (may result in hypertension).
Decreased heart rate. Decreased AV conduction. Route/Dosage
IV (Adults): Antiarrhythmic— 500-mcg/kg loading dose over 1 min initially, fol-
Pharmacokinetics lowed by 50-mcg/kg/min infusion for 4 min; if no response within 5 min, give 2nd
Absorption: IV administration results in complete bioavailability. loading dose of 500 mcg/kg over 1 min, thenqinfusion to 100 mcg/kg/min for 4 min.
Distribution: Rapidly and widely distributed. If no response, repeat loading dose of 500 mcg/kg over 1 min andqinfusion rate by
Metabolism and Excretion: Metabolized by enzymes in RBCs and liver. 50-mcg/kg/min increments (not to exceed 200 mcg/kg/min for 48 hr). As therapeu-
Half-life: 9 min. tic end point is achieved, eliminate loading doses and decrease dose increments to 25
TIME/ACTION PROFILE (antiarrhythmic effect) mg/kg/min. Intraoperative antihypertensive/antiarrhythmic— 250– 500-mcg/
kg loading dose over 1 min initially, followed by 50-mcg/kg/min infusion for 4 min; if
ROUTE ONSET PEAK DURATION no response within 5 min, give 2nd loading dose of 250– 500 mcg/kg over 1 min,
IV within minutes unknown 1–20 min thenqinfusion to 100 mcg/kg/min for 4 min. If no response, repeat loading dose of
250– 500 mcg/kg over 1 min andqinfusion rate by 50-mcg/kg/min increments (not
Contraindications/Precautions to exceed 200 mcg/kg/min for 48 hr).
IV (Children): Antiarrhythmic— 50 mcg/kg/min, may beqq 10 min up to 300
Contraindicated in: Uncompensated HF; Pulmonary edema; Cardiogenic shock; mcg/kg/min.
Bradycardia or heart block; Known alcohol intolerance.
Use Cautiously in: Geri:qsensitivity to the effects of beta blockers; Thyrotoxico- NURSING IMPLICATIONS
sis (may mask symptoms); Diabetes mellitus (may mask symptoms of hypoglyce- Assessment
mia); Patients with a history of severe allergic reactions (intensity of reactions may be ● Monitor BP, ECG, and pulse frequently during dose adjustment period and period-
increased); OB, Lactation, Pedi: Safety not established; neonatal bradycardia, hy- ically during therapy. The risk of hypotension is greatest within the first 30 min of
potension, hypoglycemia, and respiratory depression may occur rarely. initiating esmolol infusion.
⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.
Name /bks_53161_deglins_md_disk/esmolol 02/12/2014 02:26PM
2 ● Continuous Infusion: Diluent: Premixed infusions are already diluted and
● Monitor intake and output ratios and daily weights. Assess routinely for signs and
symptoms of HF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular
venous distention).
● Assess infusion site frequently throughout therapy. Concentrations ⬎10 mg/mL
may cause redness, swelling, skin discoloration, and burning at the injection site.
Do not use butterfly needles for administration. If venous irritation occurs, stop
the infusion and resume at another site.
● Toxicity and Overdose: Monitor patients receiving esmolol for signs of over-
dose (bradycardia, severe dizziness or fainting, severe drowsiness, dyspnea, blu-
ish fingernails or palms, seizures).
● IV glucagon and symptomatic care are used in the treatment of esmolol overdose.
Because of the short action of esmolol, discontinuation of therapy may relieve
acute toxicity.
Potential Nursing Diagnoses
Decreased cardiac output (Side Effects)
Implementation
● High Alert: IV vasoactive medications are inherently dangerous. Esmolol is avail-
able in different concentrations; fatalities have occurred when loading dose vial is
confused with concentrated solution for injection, which contains 2500 mg in 10
mL (250 mg/mL) and must be diluted. Before administering, have second practi-
tioner independently check original order, dose calculations, and infusion pump
settings.
● High Alert: Do not confuse Brevibloc (esmolol) with Brevital (methohexital). If
both are available as floor stock, store in separate areas.
● To convert to other antiarrhythmics following esmolol administration, administer
the 1st dose of the antiarrhythmic agent and decrease the esmolol dose by 50% af-
ter 30 min. If an adequate response is maintained for 1 hr following the 2nd dose
of the antiarrhythmic agent, discontinue esmolol.
IV Administration
● pH: 4.5– 5.5.
● Direct IV: Diluent: The 10 mg/mL and 20 mg/mL vials should be used for the
loading dose. These vials are already diluted. No further dilution is needed. Con-
centration: Avoid concentrations ⬎10 mg/mL. Rate: Administer over 1 min.
Plate # 0-Composite pg 2 # 2
ready to use. Solution is clear, colorless to light yellow. Concentration: 10 mg/
mL. Rate: Based on patient’s weight (see Route/Dosage section). Titration of PDF Page #2
dose is based on desired heart rate or undesired decrease in BP. Esmolol infu-
sions should not be abruptly discontinued; the infusion rate should be tapered.
● Y-Site Compatibility: alfentanil, amikacin, aminophylline, amiodarone, ampho-
tericin B liposome, anidulafungin, ascorbic acid, atracurium, atropine, az-
treonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, bu-
torphanol, calcium chloride, calcium gluconate, carboplatin, caspofungin,
cefazolin, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chlorprom-
azine, cimetidine, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclo-
phosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexmede-
tomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel,
dopamine, doriopenem, doxorubicin, doxycycline, enalaprilat, ephedrine, epi-
nephrine, epoetin alfa, eftifibatide, ertapenem, erythromycin, etoposide, etopo-
side phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, flu-
orouracil, folic acid, gemcitabine, gentamicin, glycopyrrolate, granisetron,
hetastarch, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, insulin,
isoproterenol, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium
sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methotrexate,
methoxamine, methyldopate, metoclopramide, metoprolol, metronidazole, mi-
cafungin, midazolam, mitoxantrone, morphine, multivitamins, nalbuphine, nal-
oxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, oc-
treotide, ondansetron, oxaliplatin, oxytocin, paclitaxel, palonosetron,
pancuronium, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine,
phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium
chloride, potassium phosphates, procainamide, prochlorperazine, promethaz-
ine, propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin,
ranitidine, remifentanil, rocuronium, sodium acetate, sodium bicarbonate, strep-
tokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thia-
mine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazo-
line, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vincristine,
voriconazole.
● Y-Site Incompatibility: acyclovir, amphotericin B cholesteryl, amphotericin B
colloidal, azathioprine, cefotetan, dantrolene, dexamethasone, diazepam, diazox-
ide, furosemide, ganciclovir, indomethacin, ketorolac, milrinone, oxacillin, pan-
toprazole, phenobarbital, phentolamine, warfarin.
䉷 2015 F.A. Davis Company CONTINUED
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esmolol
Patient/Family Teaching
● May cause drowsiness. Caution patients receiving esmolol to call for assistance
during ambulation or transfer.
● Advise patients to change positions slowly to minimize orthostatic hypotension.
● Patients with diabetes should closely monitor blood glucose, especially if weak-
ness, malaise, irritability, or fatigue occurs. Medication does not block dizziness
or sweating as signs of hypoglycemia.
Evaluation/Desired Outcomes
● Control of arrhythmias without appearance of detrimental side effects.
Why was this drug prescribed for your patient?

⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.