Pharmacy Pearl 24 NOVEMBER 1999

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A 64 year old woman presents complaining of chest "cramps" and shortness of breath for the last 2 hours. The provider begins to assess the patient when the patient suddenly collapses onto the floor. She is not breathing, has no pulse, and ECG indicates V-fib. Successive defibrillation and multiple trials of epinephrine and lidocaine are unsuccessful. The doctor wants to give bretylium, but you remind him that it is not available at your facility at this time. He then requests amiodarone IV. Do you agree or disagree? 

SELECT  here for discussion 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCUSSION 24 NOVEMBER 1999

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**THANKS to CAPT (Dr.) Loren Janke or his help with this week's Pearl **

Due to a problem with manufacturer of raw materials, pharmacies are having more and more difficulty replenishing supplies of bretylium. The unavailability of bretylium raises questions about a pharmacological "gap" in the Ventricular Fibrillation (VF)/pulseless Ventricular Tachycardia (VT) treatment algorithm.

The American Heart Association (AHA) issued a statement on Oct 12, 1999 regarding the availability of bretylium. AHA is endorsing following the algorithm without a replacement antiarrythmic agent for bretylium. AHA discusses the fact bretylium is not the first drug of choice VF/VT, and would be preceded by max doses of lidocaine. They state that, "no difference in clinical outcome or survival is observed in studies comparing lidocaine and bretylium in patients with out-of-hospital VF". They go on to say further, "Until bretylium supplies are restored or alternatives are identified, ACLS providers should follow all other protocols described in the AHA 1992 ECC algorithms for treatment of VF and VT".

Definitive data in this setting is limited, but there is a study that compared bretylium and amiodarone in recurrent VT/VF. The authors concluded that amiodarone appeared to be comparable to bretylium. This suggests that amiodarone could be used as a Class IIa intervention, although not endorsed by AHA.

Bottom line is there is no clear-cut data either for or against the use of amiodarone in VF/pulseless VT. If the provider chooses to use amiodarone, the loading dose, 150mg, (1 vial) is prepared in 100mL of D5w and given over 10 minutes. This is followed by an infusion of 1 mg/min for 6 hours, then a maintenance infusion of 0.5mg/min. The infusion is prepared by adding 6 vials to 500mL of D5W in a GLASS or rigid polyvinyl chloride bottle.  The current best estimate of availability of bretylium is mid-late January 2000 at the earliest. Product should be available from Abbott Labs, American Regent, and Raway. Wyeth Ayerst and Astra pharmaceuticals have discontinued the product.

References:

1. American Heart Association, ACLS Instructor Manual, 1997

2. Potts, J. Statement on Bretylium. AHA; October 12, 1999

3. Kowey PR, et al. Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995 Dec 1;92(11):3255-63

4. King Guide to Parenteral Admixtures.

For the AHA statement on bretylium, see www.americanheart.org/scientific/statements/1999/bretylium.html

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.

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