Maximum Rate of Esmolol in Micrograms per Kilogram per Minute
The maximum rate of esmolol is 300 micrograms per kilogram per minute, with 200 micrograms per kilogram per minute being the recommended maximum for heart rate control. 1, 2
Dosing Guidelines for Esmolol
Maximum Dosing Parameters
- For treatment of tachycardia, the American Heart Association and American College of Cardiology recommend a maximum maintenance infusion of 200 mcg/kg/min, as higher doses provide little additional heart rate-lowering effect while increasing the risk of adverse reactions 2
- For treatment of hypertension, higher maintenance infusion dosages (250 to 300 mcg/kg/min) may be required according to FDA labeling 1
- The safety of doses above 300 mcg/kg/min has not been studied 1
Standard Dosing Protocol
- Initial loading dose: 500-1000 mcg/kg/min over 1 minute 2, 3
- Initial maintenance infusion: 50 mcg/kg/min 2, 4
- Titration: Increase in increments of 50 mcg/kg/min every 5-10 minutes as needed 3, 4
- Effective maintenance dose range: 50 to 200 mcg/kg/min, although doses as low as 25 mcg/kg/min have been adequate in some patients 1, 5
Clinical Considerations
Pharmacokinetic Profile
- Ultra-short acting with elimination half-life of approximately 9 minutes (range: 4-16 minutes) 5
- Onset of action: 1-2 minutes 3
- Duration of action: 10-30 minutes 3
- Steady-state beta-blockade achieved within 5 minutes of infusion 3, 5
- Full recovery from beta-blockade occurs 18-30 minutes after terminating infusion 5
Clinical Monitoring
- Continuous cardiac monitoring is essential during esmolol administration 4
- Monitor blood pressure every 5 minutes during initial titration, then every 15 minutes once stable 3
- Monitor for signs of bradycardia, heart block, or other conduction abnormalities 3
- Watch for signs of hypoperfusion or inadequate cardiac output 3
Cautions and Contraindications
Common Adverse Effects
- Hypotension is the most frequently reported adverse effect, with incidence increasing at doses exceeding 150 mcg/kg/min 5, 6
- Hypotension may be accompanied by diaphoresis 5
- If hypotension occurs, it can usually be managed by decreasing the dose or discontinuing the infusion 5
Contraindications
- Concurrent beta-blocker therapy 2, 3
- Bradycardia or second/third-degree heart block 2, 3
- Decompensated heart failure 2, 3
- Asthma or reactive airway disease (higher doses may block beta-2 receptors) 2, 3