Improve care of patients with new cardiac drug
Do you want to be up to date on the latest cardiac treatments? If so, you should be familiar with ReoPro (abciximab), manufactured by Eli Lilly & Co. in Indianapolis.
"There is an emerging use of ReoPro and other IIb/IIIa inhibitors in the ED," reports Janet Williams, RN, MSN, CCRN, clinical trials nurse coordinator for the department of emergency medicine at the University of Cincinnati. Cardiologists have routinely used IIb/IIIa inhibitors following angioplasty and stenting procedures in the cardiac catheterization laboratory, but these medications are now given in EDs, says Williams.
Here are things you should know about ReoPro:
• Know dosages and procedures for withdrawing medication from vials.
ReoPro dosing is weight-based and given as a bolus, followed by an infusion, explains Williams. "When the medication is withdrawn from the vial, filtering is required," she says. Infusions are run at the same drip rate per hour and the concentration of the infusion changes, based on the patient’s weight, says Williams. "If the infusion is run at 21 cc/hour, as it is in my institution, a 250 cc bag will be infused in 12 hours," she explains. Less wasting of medication occurs when the infusion is run at this rate, because the typical infusion time is 12 hours, adds Williams.
• Understand the indications for the drug.
Williams points to the following indications for the use of IIb/IIIa inhibitors:
- patients who present with recurrent myocardial ischemia who are not responding to conventional medical therapy (aspirin, heparin, and nitrates);
- patients for whom percutaneous intervention is planned within 24 hours.
Initiating the ReoPro infusion in the ED for these patients allows them to be electively scheduled for coronary angiography, instead of emergently when patients are unstable and there is a greater risk of complications, says Williams. (See "Controversy: Using ReoPro with thrombolytics" in this issue.)
Interface with cardiac cath lab
• Document the start time of the infusion in the medical record.
You may be in a key position to interface with the cardiac catheterization laboratory, says Williams. "The ED nurse can help to determine if there will be a delay in transfer or may have the knowledge that the patient will require transfer to a definitive care facility," she says. Typically, post-catheterization standing ReoPro orders will be written for the infusion to run for 12 hours, says Williams. "If the infusion is started in the ED, the 12 hours will need to be calculated from that time," she says.
Intensive care unit (ICU) nurses are familiar with this medication being started in the catheterization laboratory, says Williams. "So they often will determine the end point of 12 hours by using the catheterization time as the starting point, when it is not clearly documented or reported that the infusion was initiated in the ED," she explains.
She offers the following case scenario to illustrate this point: An ICU nurse receives the patient from the catheterization lab, and admission orders are written for the ReoPro to infuse for 12 hours. The nurse realizes the amount of solution remaining in the IV bag will not allow the drip to run for 12 hours. The nurse calls pharmacy to obtain a replacement infusion bag to be hung when the current one is empty. The pharmacist explains to the nurse, if a second bag were sent to meet the 12-hour time frame order, the patient would receive more than the maximum dose allowed.
The pharmacist contacts the cardiologist to clarify the order. The cardiologist wanted the patient to receive the maximum dose, which was the entire content of the IV bag. Collaboration by the pharmacist and the nurse prompts further review of the medical record to determine the infusion start time and clarification of orders with the cardiologist. It is determined that the infusion was started in the ED and not in the catheterization laboratory, which is how the nurse was calculating the 12-time endpoint.
If this collaboration between the ED nurse, ICU nurse, pharmacist, and cardiologist had not taken place, the patient could have received an additional six hours of the infusion, which would have been over the maximum dose, says Williams.
• Know safety considerations.
There are two critical safety considerations when monitoring patients receiving ReoPro, according to Rose Lengerich, RN, BSN, a study coordinator for the Lindner Clinical Trial Center, based in Cincinnati. "Nurses should astutely observe for bleeding complications, especially in patients who are in a very low weight class of less than 80 kg," she says. Additionally, thrombocytopenia has been known to occur, so platelets counts should be monitored. "Six percent of the patients receiving a one-time dose of ReoPro and 19% of the patients receiving a subsequent dose of ReoPro will develop an antibody that could cause the patient to experience a hypersensitivity reaction or thrombocytopenia," says Lengerich.
Sources
For more information about ReoPro, contact:
• Rose Lengerich, RN, BSN, Lindner Clinical Trial Center, 2123 Auburn Ave., Suite 424, Cincinnati, OH 45219. Telephone: (513) 585-1777. Fax: (513) 585-4858. E-mail: [email protected].
• Janet Williams, RN, MSN, CCRN, Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0769. Telephone: (513) 558-8109. E-mail: [email protected].
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