1. Clinical Practice Guideline Administration of Intravenous Push Antiarrhythmic Agents (Adult) June 29, 2018 Header

2. Definitions • Arrhythmia: An arrhythmia is broadly defined as an abnormality of the heart rhythm. This CPG 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. Includes medications listed in the WRHA Parenteral Drug Manual as antiarrhythmic, calcium channel blockers or beta adrenergic blockers

3. Definitions • Continuous Cardiac Monitoring: Refers to the monitoring of the heart’s electrical activity generally by electrocardiography • IV Push (Direct): Administration of an intravenous medication diluted or undiluted into a vein using a syringe into a needless port. Must follow direction of PDM for recommended rate

4. Background • Practice concerns brought forward to the WRHA Adult Pharmacotherapy Subcommittee due to variation in understanding of the requirements to safely administer antiarrhythmic agents for the acute treatment of arrhythmias including: • What clinical settings could this occur • What education is required • What are the roles and responsibilities of team members • What are the requirements for cardiac monitoring • WRHA Cardiac Sciences Program asked to co-lead the development of CPG

5. Background • Committee formed in 2014 • Meetings took place with key stakeholders at each of the acute care sites • Identify practice concerns and potential solutions • CPG approved June, 2017 • PDM monographs updated

6. Scope • Intended to guide practice for the acute treatment of arrhythmias • Nurses may or may not be covered (per PDM) to administer IV Push (Direct) • This CPG applies to all inpatient clinical units except: • Emergency • ICU • Post anesthesia recovery unit and OR

7. Key Messages • The administration of IV push antiarrhythmic agents is guided by the PDM • Timely treatment may prevent the patient from further deterioration • Team work and communication are key to ensure timely treatment and safe monitoring

8. Recommendations • Attending physician/delegate:* • Determines the best course of action to support early intervention to optimize patient outcomes • Determines most appropriate disposition post intervention in accordance with this guideline *Decisions are made in collaboration with the care team….Communication is key

9. Recommendations • Nurses • May administer IV push antiarrhythmic agents in the clinical areas identified in the PDM, provided the nurse has: • Received education related to cardiac rhythm analysis and the assessment and treatment of arrhythmias • Continuous cardiac monitoring is available prior, during and following the administration of the medication • Attending physician/delegate immediately available to assess the patient’s response to treatment

10. Recommendations • If nurse not covered to administer the medication: • The Attending Physician/delegate will administer the medication • Continuous cardiac monitoring will be available prior, during and following the administration of the medication • The Attending Physician/delegate will remain at the bedside to assess patient response

11. Procedures • Assess your patient • Vitals signs (BP, HR, RR, cardiac rhythm (if known), & oxygen saturation) • Pain Assessment (including any chest/ischemic pain) • Mental status • Determine if your patient is deteriorating

12. Is the patient deteriorating? • Cardiac or Respiratory arrest • Patient is deteriorating and may be in imminent arrest; and/or pre-arrest clinical signs are evident, representing a significant alteration from baseline for the patient, including: • Heart rate low (<40) or high (>140) beats per minute; • SBP unusually low or high; • Altered respiratory status evidenced by respiratory distress, unusually low oxygen saturation (<90%) despite oxygen therapy, unusually low (<8) or high (>30) respiratory rate; • Decreased perfusion evidenced by decreased urinary output, possibly decreased pulses, mottling, pale, cool, clammy skin; • Acute change in consciousness, including decreased LOC or increased restlessness or agitation.

13. Cardiac Monitoring • During the administration of IV antiarrhythmic medications cardiac monitoring will be provided as outlined in the guideline • Communication is key • The team should discuss options: for example: • Potential transfer to a cardiac monitored clinical unit • Use of telemetry monitoring • Continuous 12 lead electrocardiography Significant treatment delays may cause patient deterioration

14. Documentation • Follow facility standards • Include communication that occurred between the team • Clinical changes and escalation measures • Mounting and analysis of ECG rhythm strips

15. Case Study Medicine Unit • Meet Mr. G • He is a 68 year old male admitted to a medical unit with pneumonia • PMH: Hypertension, asthma • Evening prior to discharge • Complains of feeling light headed and feels like his heart is racing (new symptoms) • Cardiac monitoring not available on the unit

16. Case Study Surgical Unit • Meet Mrs. H • 75 years old female admitted to a surgical unit with bowel resection for cancer • PMH: Chronic renal failure, previous acute myocardial infarction (ejection fraction 35% - this is low) • Intra-op bleed with estimated blood loss of 2.5 L • Fluid resuscitated due to hypotension and associated tachycardia and received total volume of 4 L of RL • Overnight on the post-op unit: • Received 125 ml/hour of maintenance IV for borderline low BP • No further evidence of bleeding • Hemoglobin stable at 82 g/L • Post-op day 1in am • Goes into rapid HR of 170/beat/minute (no cardiac monitoring)

17. Case Study Sub-Acute Unit • 82 year old frail elderly admitted to a sub-acute medicine unit with pneumonia and currently treated with IV antibiotics • PMH: Hip replacement, osteoarthritis, hypertension, history of falls • Awoke in the middle of the night: • Complaining of racing heart no other symptoms

18. Summary • CPG intended to guide the safe administration of IV push antiarrhythmic agents in a timely manner • PDMs guide practice • Your patient is deteriorating, call a Code Blue • If not, team communication is key to providing timely care to patients to prevent deterioration

19. http://www.wrha.mb.ca/extranet/eipt/files/EIPT-054.pdf Go to WRHA Intranet: click of E for evidence informed tools