From the Guidelines
Tachycardia is a common complication of intravenous (IV) infusion, particularly with medications that have adrenergic properties, and its management depends on the underlying cause and the patient's hemodynamic stability. When managing tachycardia associated with IV infusion, it is essential to first assess if the tachycardia is clinically significant (heart rate >120-130 bpm) or causing hemodynamic compromise. If the tachycardia is problematic, consider adding a beta-blocker such as esmolol (starting at 50-100 mcg/kg/min) or metoprolol (5-10 mg IV slowly) to counteract the chronotropic effects while maintaining the vasopressor support, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Some key points to consider when managing tachycardia associated with IV infusion include:
- Assessing the patient's hemodynamic stability and the underlying cause of the tachycardia
- Considering the use of beta-blockers, such as esmolol or metoprolol, to counteract the chronotropic effects of the IV infusion
- Reducing the IV infusion rate if blood pressure allows, typically decreasing by 0.02-0.05 mcg/kg/min increments while monitoring hemodynamic response
- Switching to or adding alternative medications, such as vasopressin, to maintain blood pressure with less tachycardia
- Addressing underlying causes such as hypovolemia, pain, fever, or anxiety to reduce the heart rate while continuing necessary vasopressor support
The American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care also provide recommendations for the management of tachycardia, including the use of adenosine, diltiazem, and verapamil for stable, narrow-complex tachycardias 1. However, the most recent and highest quality study, the 2015 ACC/AHA/HRS guideline, recommends the use of beta-blockers, such as esmolol or metoprolol, as the first-line treatment for tachycardia associated with IV infusion 1.
In terms of specific medications, the following can be used to manage tachycardia associated with IV infusion:
- Esmolol: starting at 50-100 mcg/kg/min
- Metoprolol: 5-10 mg IV slowly
- Adenosine: 6 mg IV as a rapid IV push followed by a 20 mL saline flush
- Diltiazem: initial dose 15 to 20 mg (0.25 mg/kg) IV over 2 minutes
- Verapamil: initial dose 2.5 to 5 mg IV given over 2 minutes
It is essential to note that the management of tachycardia associated with IV infusion should be individualized based on the patient's underlying medical condition, the severity of the tachycardia, and the patient's response to treatment. The patient's hemodynamic stability and the underlying cause of the tachycardia should be carefully assessed, and the treatment should be tailored to the specific needs of the patient.
From the FDA Drug Label
Clinically significant hypotension during infusions was seen most often in the first several hours of treatment and was not dose related, but appeared to be related to the rate of infusion. In 90 (4. 9%) of 1836 patients in clinical trials, drug-related bradycardia that was not dose-related occurred while they were receiving intravenous amiodarone for life-threatening VT/VF. Proarrhythmia, primarily torsade de pointes (TdP), has been associated with prolongation, by intravenous amiodarone, of the QTc interval to 500 ms or greater.
The relationship between tachycardia and intravenous (IV) infusion of amiodarone is that tachycardia is not directly mentioned as an effect of IV infusion. However, bradycardia is reported to have occurred in 4.9% of patients receiving IV amiodarone. Additionally, proarrhythmia, including torsade de pointes, has been associated with IV amiodarone, which can potentially lead to life-threatening arrhythmias.
- Key points:
- Bradycardia occurred in 4.9% of patients
- Proarrhythmia, including torsade de pointes, has been associated with IV amiodarone
- No direct mention of tachycardia as an effect of IV infusion 2