Administration of Intravenous Push Antiarrhythmic Agents (Adult)

Transcription

1 1 of 6 PURPOSE AND INTENT The purpose of the guideline is to facilitate the safe administration of intravenous (IV) push antiarrhythmic agents where the adult patient requires the medication in a timely manner. This guideline is intended to guide practice in clinical situations outside of the emergency department, intensive/critical care units, post anesthesia recovery room and operating room settings where the administration of (IV) push anti-arrhythmic agents may or may not be covered (as directed by the parenteral drug manual) by Registered Nurses. This guideline is not intended for patients with chronic, stable disease who are temporarily unable to take oral antiarrhythmic agents (example: following surgery). This guideline is not intended to guide care in those clinical situations where the use of antiarrhythmic agents are used for non-arrhythmic indications. 1. OUTCOME Patients will receive timely administration of intravenous IV push anti-arrhythmic agents for the acute treatment of arrhythmias including the appropriate care and treatment required prior to, during and following the administration of the anti-arrhythmic medications. 2. DEFINITIONS Arrhythmia: An arrhythmia is broadly defined as an abnormality of the heart rhythm. This document pertains to the management of fast arrhythmias also known as tachyarrhythmias. Anti-arrhythmic medications: Medications used to suppress arrhythmias and improve conduction of the heart, thus improving cardiac output. The goal of anti-arrhythmic therapy is to restore normal cardiac rhythm and/or facilitate more favorable conduction (e.g. reduce ventricular response to atrial fibrillation). An additional goal may be to prevent more serious or lethal arrhythmias. These medications would include drugs listed in the WRHA Parenteral Drug Manual (PDM) as antiarrhythmic, calcium channel blockers or beta adrenergic blockers. Continuous Cardiac Monitoring: This refers to the monitoring of the heart s electrical activity generally by electrocardiography. The decision regarding the type and duration of continuous cardiac monitoring is ultimately a physician s decision and is dependent upon available existing equipment and human resources. Options may include

2 2 of 6 bedside continuous cardiac monitoring, remote telemetry monitoring, or 12 lead electrocardiography performed at the bedside by appropriately trained personnel. 3. S/RECOMMENDATIONS 3.1 The attending physician/delegate, in collaboration with the care team, determines the best course of action to support early intervention to optimize patient outcomes. In addition, the physician will determine the most appropriate patient disposition post intervention based on the patient s clinical status 3.2 Registered Nurses who have received education related to cardiac rhythm analysis and the assessment and treatment of arrhythmias (for example: advanced assessment course offered at St. Boniface Hospital) may administer IV push antiarrhythmic agents in the clinical areas identified in the WRHA Parenteral Drug Manual provided: Continuous cardiac monitoring prior, during and following the administration of the IV push antiarrhythmic agents is available The attending physician/delegate is immediately available to assess the patient s response to treatment 3.3 The attending physician/delegate will administer IV push antiarrhythmic agents in those clinical areas where such medications are not covered by Registered Nurses provided: Continuous cardiac monitoring prior, during and following the administration of the IV push antiarrhythmic agent is available The attending physician/delegate shall remain at the bedside to assess the patient s response to treatment. The length of time will be determined by the physician s assessment of the patient s hemodynamic stability and the effects of the drug 3.4 The Administration of IV push antiarrhythmic agents is guided by the WRHA Parenteral Drug Manual 4. COMPONENTS

3 3 of Determine the patient s hemodynamic response to the alteration of their cardiac heart rhythm. This should include a minimum of: vital signs (blood pressure, heart rate, cardiac rhythm, respiratory rate, & oxygen saturation), pain assessment (including any chest/ischemic pain) and mental status 4.2 If the patient is deteriorating, or if the resources of the Code Blue Team are required, a Code Blue should be called, as indicated by the WRHA Code Blue Team Resuscitation in Acute Care Policy (Policy ) 4.3 If a Code Blue is not indicated: Request a stat 12 lead ECG. It is recommended that all facilities have a process in place to ensure that a 12 lead ECG may be ordered without delay (for example: development of a protocol) Notify the appropriate physician/delegate immediately of a change in patient s clinical status If oxygen saturation is less than 90% or there is evidence of respiratory distress, establish supplemental oxygen, titrate to SaO 2 greater than or equal to 90% Establish peripheral intravenous access or confirm patency of pre-existing intravenous access Establish continuous cardiac monitoring: For patient care areas without readily access to continuous cardiac monitoring and the patient does not meet criteria for Code Blue, discuss alternatives with the physician such as transferring the patient to a cardiac monitored clinical unit or the use of telemetry monitoring Administer intravenous antiarrhythmic agents as per the WRHA parenteral Drug Monograph. Follow the WRHA parenteral drug monograph assessment parameters and additional notes/considerations 5. DOCUMENTATION: Follow facility specific policy and procedures regarding documentation standards. Consideration should be given to document any communication amongst health care

4 4 of 6 providers, clinical changes, escalation measures, as well as documentation (including mounting and analysis) of ECG rhythm strips. 6. REFERENCES: (1) AHA/ACC/HRS Guidelines for the Management of Patients with Atrial Fibrillation. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences. (2014). JACC, 64(21), e1-76. Retrieved April 20, 2017from doi: /j.jacc (2) Chen, E. (2014). Appropriate use of telemetry monitoring in hospitalized patients. Curr Emerg Hosp Med Rep, 2, doi: /s (3) Drew, B. J., Califf, R. M., Funk, M., Kaufman, E. S; Krucoff, M., Laks, M., & Van Hare, G. (2004). Practice standards for electrocardiographic monitoring in hospital settings. Circulation, 110: Retrieved April 20, 2017 from: doi.org/ /01.cir (4) Kumar, D. (2008). Cardiac monitoring: New trends and capabilities. 38(3). Retrieved April 20, 2017 from: (5) Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., & Morrison, L. J. (2010). Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation; 122 (supplemental 3): S729-S767. Retrieved April 20, 2017 from: doi: /CIRCULATIONAHA

5 5 of 6 (6) Throndson, K.L. (2014). Draft Guideline: Cardiac monitoring of inpatients with acute arrhythmias receiving intravenous antiarrhythmic medications (adult). Health Sciences Centre, Winnipeg: Author. 7. PRIMARY AUTHORS Co-Leads: Ms. Christina Kuttnig, CEI, Cardiac Sciences Program, SBH Dr. Lorraine Avery, CNS, Cardiac Sciences Program, WRHA Members: Mr. Giuseppe Aletta, Pharmacist, Department of Pharmacy, SBH Dr. Ivan Barac, Cardiologist, Cardiac Sciences Program, WRHA Mr. Reid Love, Program Director, Cardiac Sciences Program, WRHA Ms. Karen Coupland, CEI Cardiac Sciences Program, SBH Dr. Pat Honcharik, Pharmacist, Regional Pharmacy Manager, WRHA Mr. Steve Klassen, Patient Care Team Manager Cardiac Sciences Program, WRHA Ms. Rosanne Labossiere-Gee, Patient Care Team Manager, Cardiac Sciences Program, SBH Ms. Donna Lee Sampson, Patient Care Team Manager, Cardiac Sciences Program, SBH Dr. Kunal Minhas, Director, Coronary Care Unit, Cardiac Sciences Program, WRHA Dr. Colette Seifer, Medical Director Cardiology, Cardiac Sciences Program, WRHA Dr. James Tam, Cardiologist, Cardiac Sciences Program, WRHA Ms. Karen Throndson, CNS Cardiac Sciences Program, WRHA Ms. Sandy Warren, CEI Cardiac Sciences Program, SBH Subject Matter Experts Consulted: Dr. David Easton, Director Intensive Care Unit, GGH Dr. Gregg Eschun, Program Director Respiratory Medicine SBH, Unit Director SBH-Surgical Intensive Care Unit Dr. Patrick Griffin, Site Medical Manager of Internal medicine Programs VGH

6 6 of 6 Dr. Nick Hajidiacos, Medical Manager Medicine, SBH Dr. Ramin Hamedani, Internal Medicine, GGH Dr. Davinder Jassal, Cardiologist, Cardiac Sciences Program, WRHA & Head Section of Cardiology University of Manitoba Ms. Kerstin L. Jordan, Clinical Manager ICU, CGH Dr. Ricardo Labato de Faria, Chief Medical Officer, SOGH Dr. Kendiss Olafson, Medical Director ICU, CGH Dr. Heather Smith, Medical Director ICU, VGH Ms. Lori Ulrich, Director of Specialty Care Programs, VGH