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7/29/22 mc Calcium Channel Blocker and Beta Blocker Overdose - New PowerPlans
August 3, 2022

From: "Monroe Crawley" <monroe.crawley@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>
Sent: Friday, July 29, 2022 2:37:33 PM
Subject: Calcium Channel Blocker and Beta Blocker Overdose - New PowerPlans

 

Pharmacists,

Two new PowerPlans are now built and available for managing adult patients with acute toxicity related to calcium channel blocker overdose or beta blocker overdose.

ED Adult Calcium Channel Blocker Toxicity Management Orders
 
ED Adult Beta Blocker Toxicity Management Orders

Here are a few key points to keep in mind when verifying these orders:
  • ED Adult Calcium Channel Blocker Toxicity Management Orders
    • Calcium administration is pre-checked for 3 doses as needed for SBP < 90 mmHg
      • If the patient responds hemodynamically, a continuous calcium infusion may be warranted.
      • Continuous IV calcium gluconate infusion should be titrated to maintain an ionized calcium of 1.1 - 1.35 mmol/L
    • Glucagon administration is not recommended in CCB overdose 
  • ED Adult Beta Blocker Toxicity Management Orders
    • Glucagon administration is pre-checked for 2 doses as needed for HR < 50 bpm and SBP < 90 mmHg
      • Given 30 minutes after ondansetron
      • If patient responds hemodynamically to glucagon therapy, a continuous glucagon infusion may be warranted
      • Continuous IV glucagon infusion should be titrated to maintain MAP > 65 mmHg, SBP > 90 mmHg, and HR > 60 bpm
Important points for BOTH PowerPlans:
  • High Dose Insulin Euglycemic Therapy (HDIET)
    • If warranted, HDIET requires concurrent insulin and dextrose infusions
    • Continuous insulin infusion will start at a rate of 0.5 units/kg/hr **NOTE: This is a much higher starting rate for an insulin infusion specifically indicated for managing CCB/BB toxicity.**
      • NEW INSULIN CONCENTRATION - Insulin, regular 3000 units/250 mL
        • Given the increased dose requirements for insulin infusions utilized for this indication, a new concentrated insulin product will be associated with these PowerPlans only.
        • The pharmacist should ensure the RN is aware of the change in insulin concentration when administering to the patient. This product is programmed into our institutional infusion pumps. 
      • This insulin infusion MUST be accompanied by a continuous dextrose infusion - either D10W or D20W
        • The pharmacist should ensure adequate blood glucose monitoring ordered appropriately
      • The insulin infusion rate will be titrated to maintain SBP > 90 mmHg and MAP > 65 mmHg **The insulin infusion should not be titrated based on blood glucose**
      • The continuous dextrose infusion will be titrated to maintain a blood glucose of 150 - 200 mg/dL
 
  • Vasopressor therapy
    • If vasopressor therapy is initiated while on HDIET, the insulin infusion should not be weaned unless specified by the provider
    • If the patient is on HDIET and vasopressor therapy, titrate off vasopressor therapy prior to weaning insulin infusion
  • Methylene blue
    • May be ordered for refractory hypotension while on HDIET and vasopressor therapy
    • Do not administer to patients on SSRIs or other pharmacotherapy contraindicated with methylene blue
  • Lipid emulsion
    • Not well supported in the literature. Should not be prioritized over other therapies.
    • Intralipid 20% will need to be administered with a 1.2 micron filter, administration with a smaller filter (like the 0.2 micron filter used with amiodarone infusions) will result in a clogged line and delayed administration to the patient
    • May be more beneficial for calcium channel blockers and lipophilic beta-blockers
  • Automatic Consult to Pharmacy
    • Ensure appropriate medication monitoring, administration, dosing, and assistance for nurses and providers as listed above.

If you have any questions, please do not hesitate to email me. Thank you.






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