Names and pronunciation
(ez′moe-lole) Brevibloc
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Drug reference
(ez′moe-lole) Brevibloc
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Func. class.: Beta-adrenergic blocker (antidysrhythmic II)
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Do not confuse: Brevibloc/Brevital
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ACTION: Competitively blocks stim- ulation of β1-adrenergic receptors in the myocardium; produces negative chronotropic, inotropic activity (decreases rate of SA node discharge, increases recovery time), slows con- duction of AV node, decreases heart rate, decreases O2 consumption in myo- cardium; also decreases renin-aldoste- rone-angiotensin system at high doses; inhibits β2-receptors in bronchial sys- tem at higher doses
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USES: Supraventricular tachycardia, noncompensatory sinus tachycardia, intraoperative and postoperative tachy- cardia and hypertension, atrial fibrilla- tion/flutter
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CONTRAINDICATIONS: Second- or third-degree heart block; cardiogenic shock, HF, cardiac failure, hypersensitiv- ity, severe bradycardia Precautions: Pregnancy, breastfeeding, geriatric patients, hypotension, periph- eral vascular disease, diabetes, hypogly- cemia, thyrotoxicosis, renal disease, atrial fibrillation, bronchospasms, hyper- thyroidism, myasthenia gravis, asthma, COPD, CV disease, pheochromocytoma, abrupt discontinuation
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SIDE EFFECTS CNS: Confusion, drowsiness, weakness, dizziness, fatigue, headache CV: Hypotension, peripheral ischemia GI: Nausea, vomiting, anorexia INTEG: Inflammation at site, sweating
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INTERACTIONS • Avoid use with MAOIs, Sotalol Increase: effect of antidiabetics Increase: possible fatal B/P increase— clonidine Increase: potentiate suppressive effects of dilTIAZem, verapamil Increase: antihypertensive effect—gen- eral anesthetics Increase: digoxin levels—digoxin Increase: alpha-adrenergic stimulation— ePHEDrine, EPINEPHrine, amphetamine, norepinephrine, phenylephrine, pseudo- ePHEDrine Decrease: action of thyroid hormones Decrease: action of esmolol—thyroid hormone, salicylates Drug/Herb Increase: beta-blocking effect—hawthorn Decrease: antihypertensive effect— ephedra Drug/Lab Test Interference: glucose/insulin tolerance test
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TREATMENT OF OVERDOSE: Discontinue product; IV glucagon if needed
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DOSAGE AND ROUTES Atrial fibrillation/flutter • Adult: IV loading dose 500 mcg/kg/ min over 1 min; maintenance 50 mcg/kg/ min for 4 min; if no response after 5 min, give second loading dose, then increase infusion to 100 mcg/kg/min for 4 min; if no response, repeat loading dose, then increase maintenance infusion by 50 mcg/kg/min (max of 200 mcg/kg/min); titrate to patient response • Child: IV total loading dose of 600 mcg/kg over 2 min, maintenance IV IN- FUSION 200 mcg/kg/min, titrate upward by 50-100 mcg/kg/min q5-10min until B/P, heart rate reduced by >10% Perioperative hypertension/ tachycardia • Adult: IV immediate control 80 mg (bolus) over 30 seconds, then 150 mcg/ kg/min, adjust to response, max 300 mcg/kg/min, perioperative hypertension, 200 mcg/kg/min (tachycardia)
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Available forms: Injection 10 mg/mL, 10 mg/mL in 250-mL bag, 20 mg/mL in 100-mL bag
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Administer: • Do not discontinue product suddenly • Store protected from light, moisture, in cool environment IV route • Check that correct concentration is being given IV direct route • 10 mg/mL injection solution needs no dilution, may be used as an IV loading dose using a handheld syringe Continuous IV INFUSION route • Ready-to-use bags of premixed isotonic solution of 10 mg/mL and 20 mg/mL avail- able in 100-, 250-mL bags; use controlled infusion device, central line preferred; rate is based on patient’s weight Y-site compatibilities: Amikacin, ami nophylline, amiodarone, atracurium, butor- phanol, calcium chloride, ceFAZolin, cefTAZidime, ceftizoxime, chloramphenicol, cimetidine, cisatracurium, clindamycin, dil- tiazem, DOPamine, enalaprilat, erythromy- cin, famotidine, fentaNYL, gentamicin, insu- lin (regular), labetalol, magnesium sulfate, methyldopate, metroNIDAZOLE, midazolam, morphine, nitroglycerin, nitroprusside, nor- epinephrine, pancuronium, penicillin G potassium, piperacillin, polymyxin B, potas- sium chloride, potassium phosphate, propo- fol, ranitidine, remifentanil, streptomycin, tacrolimus, tobramycin, trimethoprim- sulfamethoxazole, vancomycin, vecuronium, voriconazole, zoledronic acid
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Assess: • Heart failure: I&O ratio, weight daily, jugular venous distention, weight gain, crackles, edema • Dysrhythmias: B/P, pulse; note rate, rhythm, quality; rapid changes can cause shock; if systolic <100 or diastolic <60, notify prescriber before giving product; ECG continuously during infusion, hypo- tension common, if severe, slow or stop infusion • Infusion site: monitor infusion site dur- ing infusion; do not use butterfly if irrita- tion occurs; stop and start at another site • Bronchospasm: breath sounds, respi- ratory pattern • Pregnancy/breastfeeding: use only if benefit outweighs risk to fetus; use in the last trimester or labor or obstetric deliv- ery has resulted in fetal bradycardia; not known if excreted in breast milk
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Evaluate: • Therapeutic response: lower B/P im- mediately, lower heart rate
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • Not to drive or perform other hazard- ous activities if drowsiness occurs • To change positions slowly to prevent orthostatic hypotension • About reason for use; expected results • To notify prescriber if chest pain, SOB, wheezing, hypotension, bradycardia, pain, swelling at IV site occurs • Pregnancy/breastfeeding: identify if pregnancy is planned or suspected E
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PHARMACOKINETICS Onset very rapid, duration short, half-life 9 min, metabolized by hydrolysis of ester linkage, excreted via kidneys
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• Adult: IV loading dose 500 mcg/kg/ min over 1 min; maintenance 50 mcg/kg/ min for 4 min; if no response after 5 min, give second loading dose, then increase infusion to 100 mcg/kg/min for 4 min; if no response, repeat loading dose, then increase maintenance infusion by 50 mcg/kg/min (max of 200 mcg/kg/min); titrate to patient response
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• Adult: IV immediate control 80 mg (bolus) over 30 seconds, then 150 mcg/ kg/min, adjust to response, max 300 mcg/kg/min, perioperative hypertension, 200 mcg/kg/min (tachycardia)
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