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(ESS-moe-lahl HIGH-droe-KLOR-ide)
Brevibloc
Class: Beta-adrenergic blocker

 Action Blocks beta-receptors primarily affecting cardiovascular system (decreases heart rate, contractility and BP) and lungs (promoting bronchospasm).

 Indications Short-term management of supraventricular tachyarrhythmias and noncompensatory sinus tachycardia. Unlabeled use(s): Treatment of caffeine toxicity; attenuation of cardiovascular responses to electroconvulsive therapy or induction of anesthesia; adjunct therapy for acute MI and unstable angina; treatment of thyroid storm.

 Contraindications Sinus bradycardia; second- or third-degree heart block; CHF unless secondary to tachyarrhythmia treatable with beta-blockers; overt cardiac failure; cardiogenic shock.

 Route/Dosage

ADULTS: Usual: IV 500 mcg/kg/min for 1 min; then infusion of 50–200 mcg/kg/min, which has been titrated to desired endpoint (eg, heart rate, BP) in 50 mcg/kg/min increments.

 Interactions

Clonidine: May enhance or reverse antihypertensive effect; potentially life-threatening increases in BP may occur, especially on withdrawal. NSAIDs: Some agents may impair antihypertensive effect. Prazosin: Potential for and degree of orthostatic hypotension may be increased. Verapamil: Effects of both drugs may be increased. INCOMPATIBILITIES: 5% Sodium Bicarbonate Injection.

 Lab Test Interferences Antinuclear antibodies may develop; usually reversible on discontinuation. May interfere with glucose or insulin tolerance test results. May cause changes in serum lipid levels.

 Adverse Reactions

CV: Hypotension; bradycardia; CHF; cold extremities; pallor; second or third-degree heart block. CNS: Insomnia; fatigue; dizziness; depression; lethargy; drowsiness; forgetfulness. DERM: Rash; hives; fever; alopecia. EENT: Dry eyes; blurred vision; tinnitus; slurred speech; sore throat. GI: Nausea; vomiting, diarrhea; dry mouth. GU: Impotence; painful, difficult or frequent urination. HEMA: Agranulocytosis; thrombocytopenia purpura. RESP: Bronchospasm; shortness of breath; wheezing. OTHER: Weight changes; facial swelling; muscle weakness; inflammation at infusion site.

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Anaphylaxis: Deaths have occurred; aggressive therapy may be required. CHF: Administer drug in patients with CHF controlled by digitalis and diuretics. Notify physician at first sign or symptom of CHF or other unexplained respiratory symptoms. Diabetes mellitus: May mask signs and symptoms of hypoglycemia (eg, tachycardia, BP changes). May potentiate insulin-induced hypoglycemia. Nonallergic bronchospasm (eg, chronic bronchitis, emphysema): Use caution in patients with bronchospastic diseases. Peripheral vascular disease: May precipitate or aggravate symptoms of arterial insufficiency. Renal/hepatic impairment: Reduced daily dose advised. Thyrotoxicosis: May mask clinical signs (eg, tachycardia) of developing or continuing hyperthyroidism. Abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Avoid concentrations > 10 mg/min in order to minimize venous irritation.
  • 10 mg/ml vial does not need further dilution.
  • Do not administer through butterfly needles.
  • For IV administration, use 250 mg/ml solution diluted in 5% Dextrose Injection and 0.9% or 0.45% Sodium Chloride Injection, Lactated Ringer’s Injection, and Potassium Chloride (40 mEq/L) in 5% Dextrose Injection or 0.9% or 0.45% Sodium Chloride Injection. To prepare solution remove 20 ml from 500 ml bottle of suitable infusion fluid and add 2 amps of 250 mg/ml solution of esmolol. Final concentration is 10 mg/ml.
  • Do not mix with sodium bicarbonate.
  • Store diluted solution at room temperature or under refrigeration. Discard after 24 hr.
  • Use of esmolol infusion up to 24 hr is well documented. Limited data indicate that esmolol is well tolerated up to 48 hr.
  • When converting patient to another agent, reduce esmolol infusion rate by 50% ½ hr after first dose of new drug. After second dose of new drug, if patient is stable for 1 hr, discontinue esmolol infusion.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Obtain baseline ECG and measure QT interval.
  • Obtain baseline vital signs and weight.
  • Auscultate and document baseline heart and lung sounds and monitor throughout therapy.
  • Monitor vital signs frequently.
  • Monitor I&O, BUN, creatinine, serum glucose, CBC, liver function tests and bilirubin throughout therapy.
  • Assess patient for rashes, urticaria, shortness of breath, arthralgia and systemic lupus erythematosus syndrome.
  • If reaction develops at infusion site, use alternative site.
  • Notify physician if vomiting, abdominal distention, vertigo, bradycardia, new ventricular arrhythmia, shock symptoms or signs of CHF occur.
  • If patient is receiving digoxin, monitor digoxin levels and observe patient for digoxin toxicity.
OVERDOSAGE: SIGNS & SYMPTOMS
  Hypotension, bradycardia, intraventricular conduction disturbances, shock

 Patient/Family Education

  • Caution patient to notify physician or nurse of any urticaria, shortness of breath, vertigo, syncope or inability to void.
  • Advise diabetic patient to notify physician or nurse of hypoglycemic reaction symptoms.

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