All Critical Care Areas
Cardiac DOU
ABCIXIMAB (REOPRO™)

ROUTES OF ADMINISTRATIONDirect IV push and continuous IV administration
METHOD FOR IV ADMINISTRATION AND DOSAGE
  1. Bolus dose: 0.25 mg/kg IVP over 1 - 2 minutes. The bolus does not require a filter.
  2. Infusion dose: 0.125 mcg/kg/minute (maximum 10 mcg/minute) continuous IV infusion should immediately follow the bolus dose. The infusion dose should be administered with an in-line 0.22 micron filter via an IV infusion pump.
  3. The duration of treatment is 12 hours after start of infusion post-percutaneous coronary intervention.
  4. Readministration of abciximab is not recommended within 6 months of prior use (See comments).
  5. Abciximab should be administered via a separate intravenous line and not mixed with other medications.
  6. See appendix for weight-adjusted dosing information.
INDICATIONS FOR IV USEDuring percutaneous coronary intervention (PCI) and post-PCI.
MONITORING PARAMETERS
  1. Baseline CBC, PT, aPTT; optional fibrinogen.
  2. ACT should also be measured for patients undergoing percutaneous coronary intervention.
  3. Platelet count 4-6 hours and again 18-24 hours after the bolus dose.
  4. Guaiac testing of stools and testing of urine for occult blood as clinically indicated.
POTENTIAL PROBLEMS WITH IV ADMINISTRATION
  1. Increased bleeding risk
  2. Thrombocytopenia
  3. Hypersensitivity reaction
TREATMENT OF ADVERSE EFFECTS
  1. Excessive bleeding: Maintain bleeding precautions, and avoid unnecessary arterial and venous punctures. If bleeding cannot be controlled with pressure, consider discontinuing infusion of abciximab and heparin. If platelet count decrease to < 100,000/mm3, abciximab and any concomitant heparin should be discontinued. The physician should be contacted immediately.
  2. Hypersensitivity reaction: Epinephrine, dopamine, theophylline, diphenhydramine, and methylprednisolone should be available for immediate use. Discontinue abciximab infusion and contact the physician immediately if symptoms of an allergic reaction appear.


CONTRAINDICATIONS
  1. Active internal bleeding.
  2. Recent (within six weeks) gastrointestinal or genitourinary bleeding of clinical significance.
  3. History of cerebrovascular accident (CVA) within two years, or CVA with a significant residual neurologic deficit.
  4. Bleeding diathesis.
  5. Administration of oral anticoagulants within 7 days unless prothrombin time is 1.2 times control.
  6. Platelet count < 100,000/mm3
  7. Recent (within 6 weeks) major surgery or trauma.
  8. Intracranial neoplasm, arteriovenous malformation, or aneurysm.
  9. Severe uncontrolled hypertension (systolic BP>200 or diastolic BP>110 mmHg).
  10. Presumed or documented history of vasculitis
  11. Use of intravenous dextran before PCI, or intent to use it during an intervention.
  12. Hypersensitivity to any component of ReoPro or human-murine proteins.
PRECAUTIONS
  1. Arterial and venous punctures and the use of urinary foley catheters, nasogastric tubes or nasotracheal intubation should be minimized.
  2. IM injections should be avoided.
  1. Use of non-compressible site (subclavian or jugular veins) is discouraged when obtaining an IV access.
COMMENTS
  1. Safety and efficacy of ReoPro readministration is currently under investigation. The most serious adverse effects of readministration are the potential for life-threatening thrombocytopenia (up to 12%) and increased incidence of intracranial hemorrhage (up to5.3%).
  2. Hematological effects include irreversible binding to platelet GP IIb/IIIa receptor sites. Produces >80% receptor blockade two hours after administration of the IV bolus dose. Correction of platelet function occurs over 48-72 hours after the infusion is discontinued.
REFERENCES
  1. Centocor/Eli Lilly & Company. Reopro (abciximab) package insert. Indianapolis, IN: November 1997.
  2. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330:956-961.
  3. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low dose heparin during percutaneous coronary revascularization. N Engl J Med 1997;336:1689-1696.
  4. The EPISTENT Investigators. Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein-IIb/IIIa blockade. Lancet 1998; 352(9122):87-92.
  5. The CAPTURE Investigators. Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina. Lancet 1997e; 349:1429-1435.
  6. Efficacy of abciximab readministration in coronary intervention. Am J Cardiol 2000;85:435-440
ApprovalClinical Policy & Procedure Committee (January 2003)
Pharmacy & Therapeutics Committee (January 2003)
F:\ADULT IV Administration Guidelines\abciximab.doc Revi 12/02A

​Non-Critical Care Areas
All Critical Care Areas
ACETAZOLAMIDE (DIAMOX)

ROUTES OF ADMINISTRATIONIV push, IM (IM injection is very painful due to pH of 9.2 and not recommended)
METHOD FOR IV ADMINISTRATION
  1. Each 500 mg must be diluted with 5 mL of sterile water for injection to prevent hypertonicity.
  2. May be administered IV push at 100 – 500 mg/minute.
  3. Doses greater than 1 gram per 24 hours do not produce increased effect.
INDICATIONS FOR IV USE AND DOSAGE
  1. Diuresis (e.g., in CHF): 5 mg/kg once daily
  2. Chronic simple (open-angle) glaucoma: 250 - 500 mg, may repeat in 2 - 4 hours.
  3. Secondary or acute congestive (closed-angle) glaucoma: 250 mg every 4 - 12 hours.
  4. Epilepsy: 8 - 30 mg/kg/day in divided doses (maximum dose: 1 gram/day).
  5. Drug-induced edema: 250 - 375 mg once daily.
  6. Metabolic alkalosis: 250 - 500 mg every 12 hours.
POTENTIAL PROBLEMS WITH IV ADMINISTRATION
  1. Acetazolamide is a sulfonamide derivative and may cause hypersensitivity reactions (e.g., urticaria, fever, blood dyscrasias).
  2. Central nervous system effects (e.g., drowsiness, dizziness and paresthesias) have occurred at high doses.
TREATMENT OF ADVERSE SIDE EFFECTS
  1. Hypersensitivity reactions: epinephrine, corticosteroids and/or antihistamines may be used.
  2. Paresthesias and drowsiness decrease with lower doses or discontinuation of the drug.
COMMENTS
  1. Long-term use of acetazolamide may result in acidosis, kidney stones, blood dyscrasias, myopia and teratogenic effects in the fetus.
  2. Acetazolamide is contraindicated in adrenal failure, hyponatremia, hypokalemia, and severe kidney or liver dysfunction.
  3. Since it contains no preservatives, the reconstituted solution should be used within 12 hours if stored at room temperature or 3 days if refrigerated.
REFERENCES
  1. Diamox product information.
  2. Trissel LA, Handbook on Injectable Drugs, American Society of Hospital Pharmacists, Washington DC, 10th Edition,1998:3.
  3. Martin WJ, Matzke GR. Treating severe metabolic alkalosis. Clin Pharm. 1982;1:42-8.
  4. American Hospital Formulary Service 1997; 52:10.
  5. Facts and Comparisons 1/2000; pp 634, 1338.
ApprovalClinical Policy & Procedure Committee (July 2002)
Pharmacy & Therapeutics Committee (July 2002)
F:\ADULT IV Administration Guidelines\acetazolamide.doc Rev. 07/02

​All Critical Care Areas
Cardiac DOU
Medical DOU/Cardiac Telemetry-limited use as specified below
ADENOSINE (ADENOCARD®)

ROUTES OF ADMINISTRATIONIV push
METHODS FOR IV ADMINISTRATION AND DOSAGE

  1. Adenosine is supplied as a 6 mg/2 mL vial.
  2. Recommended doses of adenosine are as follows:
  • Initial dose: 6 mg given direct IV push over 1-2 seconds
  • Repeat administration: 12 mg direct IV push can be given if the patient does not respond to the initial dose within 2 minutes. May repeat 12 mg again within 1-2 minutes if necessary. The maximum total dose that may be given is 30 mg.
  • Individual doses greater than 12 mg are not recommended.
  1. To ensure immediate delivery, adenosine injection should be administered either directly into a vein, or if given into an IV line, it should be administered through the port closest to the patient and followed by a rapid saline flush.
  2. The half-life of adenosine is less than 10 seconds. Dosage adjustment is not required in the presence of renal or hepatic impairment.
  3. Medical DOU/Telemetry Areas: Adenosine may be administered to stabilize patients in unstable PSVT. Physician must be present at bedside and bedside monitoring is required.
INDICATIONS FOR IV USEConversion to normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT) with or without Wolff-Parkinson-White syndrome. Adenosine does not convert atrial fibrillation or flutter to a sinus rhythm.
MONITORING PARAMETERS
  1. Heart rate
  2. Blood pressure
  3. Bedside ECG monitoring
POTENTIAL PROBLEMS WITH IV ADMINISTRATION
  1. Arrhythmias at the time of conversion – premature contractions, sinus bradycardia, sinus tachycardia, skipped beats, and varying degrees of A-V block may appear on the electrocardiogram at time of conversion to normal sinus rhythm. Such findings have occurred in about 55% of the patients and generally last for a few seconds, do not compromise the patient’s hemodynamic status, and do not require intervention.
  2. Cardiovascular: facial flushing (18%), chest pain (<1%)
  3. Pulmonary: dyspnea (12%), hyperventilation (<1%)
  4. Central Nervous System: lightheadedness (2%), numbness, blurred vision (<1%)
  5. Gastrointestinal: nausea (3%), metallic taste, pressure in groin (<1%)
TREATMENT OF ADVERSE EFFECTS
  1. Bradycardia, AV block and other arrhythmias: discontinue therapy. Since adenosine has a short half-life, side effects are generally self-limiting. A pacemaker should be available when treating patients with a known predisposition to bradycardia or AV block.. Other appropriate resuscitative measure should be available when administering adenosine.
  2. Bronchospasm, dyspnea: discontinue therapy. May administer a beta-agonist such as albuterol aerosolized inhalation with or without ipratropium inhalation.
  3. Flushing: the effect is generally transient and subsiding in most patients in a few seconds.
CONTRAINDICATIONS (unless a functioning A.V. sequential pacer present)
  1. Second or third degree A-V block
  2. Sick sinus syndrome or symptomatic bradycardia
PRECAUTIONS
  1. Bronchoconstriction: may occur in patients with asthma and therefore the use of adenosine should be discouraged. Adenosine should be used cautiously in patients with obstructive pulmonary disease since respiratory compromise has occurred in these patients.
  2. Adenosine potentially interacts with the following drugs:
  • Methylxanthines such as theophylline, pentoxifylline and caffeine antagonize the adenosine effect.
  • Dipyridamole can enhance the effect of adenosine.
  • Carbamazepine can enhance the degree of AV block.
  • Rarely, ventricular fibrillation has occurred in patients already receiving digoxin or the combination of digoxin and verapamil.
REFERENCES
  1. Fujisawa Healthcare. Adenocard package insert. Deerfield, IL;1996 July
  2. Drug Facts and Comparisons.2001
ApprovalClinical Policy & Procedure Committee (January 2003)
Pharmacy & Therapeutics Committee (January 2003)
F:\ADULT IV Administration Guidelines\adenosine.doc Rev 12/02