PLACE LABEL HERE

CORVERT (ibutilide)

ATRIAL FIBRILLATION/FLUTTER

PROTOCOL

The following orders will be implemented per physician order of this protocol.

Orders with a “” are indicator choices and are NOT implemented unless checked.

1.Patient’s Actual Weight ______kg

2.Restricted to Cardiologists and Emergency Department (ED) Physicians

3.Physician or assigned midlevel to be present during infusion.

4.Restricted to ICU, IMCU, PCU, ED, ARU, 5N

5.Pre-Infusion Check List

Nurse to confirm that all questions below are answered “yes”. If “No” answer, follow orders as indicated in the chart below. Corvert (ibutilide) may only be administered if all below questions are answered with a “Yes”:

Yes / Requirements Prior to Administration / Response if No:
DO NOT ADMINISTER CORVERT (ibutilide)
‮ /
  • Is the Potassium (K) level 4 within the past 24 hrs?
/
  • Draw stat potassium level
  • If level < 4, call physician for replacement orders prior to administration of Corvert (ibutilide) and recheck potassium level 1 hr after replacement completed

‮ /
  • Is the Magnesium (Mg) level 2 within the past 24 hrs?
/
  • Draw stat magnesium level
  • If level < 2, call physician for replacement orders prior to administration of Corvert (ibutilide) and recheck Mg level 1 hr after replacement completed

  • Is 12-lead EKG in place and to be performed for baseline and during Corvert (ibutilide) infusion and cardiac monitoring for a minimum of 4 hrs after administration?
/
  • Continuous cardiac monitoring for any arrhythmia activity or persistent QTc prolongation

  • Is an ACLS certified nurse or physician present to monitor patient during and following Corvert (ibutilide)administration?
/
  • Transfer patient to an appropriate unit described in #4 above

  • Physician or midlevel documented baseline QTc by signing EKG and approved to administer Corvert (ibutilide).
/
  • Have physician or midlevel monitor and document QTc on baseline EKG.

  • Confirmed that patient isNOTcurrently or has previously taken any of the following medications: amiodarone, dronedarone, quinidine, procainamide, disopyramide, sotalol, dofetilide, flecainide or propafenone of other drugs known to prolong QT interval.
/
  • If currently or previously taken a medication listed to the left, date last taken______
  • Physician was informed (Dr.______, date/time______) and approved to administer.

‮ /
  • Is the patient still in atrial fibrillation immediately prior to administration of Corvert (ibutilide)?
/
  • Notify physician if patient has converted and no longer in atrial fibrillation

Copy to pharmacy

*3-21578* FORM 3-21578 REV. 02/2016 Page 1 of 2

PLACE LABEL HERE

CORVERT (ibutilide)

ATRIAL FIBRILLATION/FLUTTER

PROTOCOL

The following orders will be implemented per physician order of this protocol.

Orders with a “” are indicator choices and are NOT implemented unless checked.

Corvert Dose and Administration:

6. Give Magnesium Sulfate 2 Gm IVPB over 10 minutes immediately prior to Corvert administration unless magnesium level > 3 or dialysis patient.

7. 12-lead EKG monitoring during infusion.

8. Corvert (ibutilide) Dosing:

Patient’s weight 65 kg, give Corvert (ibutilide) 1 mg, slow IV push over 10 minutes

Patient’s weight 60 kg - 65 kg, physician to evaluate and determine best dosing regimen:

giveCorvert (ibutilide) 1 mg, slow IV push over 10 minutes

give Corvert (ibutilide) 0.01 mg/kg, slow IV push over 10 minutes

Patient’s weight 60 kg, give Corvert (ibutilide) 0.01 mg/kg,slow IV push over 10 minutes

Corvert Infusion Monitoring Check List

9. Nurse to confirm that all questions below are answered “yes”. If “No” answer, follow orders as indicated in the chart

below.

Yes / Requirements During and After Administration / Response if No:
DO NOT ADMINISTER CORVERT (ibutilide)
Check QTc interval at 5 minutes into Corvert (ibutilide) administration by a 12-lead EKG and copy in medical record.
  • Is QTc 500 ms at 5 minutes into infusion?
/
  • If QTc > 500ms, notify ordering physician immediately and stop Corvert (ibutilide) infusion

Check QTc interval at the end of Corvert (ibutilide) administration by a 12-lead EKG and copy in medical record.
  • Is QTc 500 ms at end of infusion?
/
  • If QTc > 500ms, notify ordering physician immediately

  • The following medications are not currently ordered: amiodarone, dronedarone, quinidine, procainamide, disopyramide, sotalol, dofetilide, flecainide or propafenone within 4 hours post Corvert administration or other QT prolonging drugs.
/
  • Confirm with physician. Risk may outweigh benefit byprolonging QTc interval and risk of torsade.

4 Hour Post- Infusion Monitoring

10. Continuous cardiac monitoring 4-hours post infusion.

11.  Give additional Magnesium 2 Gm IVPB over 1 hour post infusion Corvert

12. Monitor for QTc prolongation 500 ms, V-tach, new onset PVCs, or bradycardia 50 bpm. Run a 12-lead EKG and

call physician if any develop.

13. At end of 4 hours post infusion, run final 12-lead EKG and have physician review and document final rhythm.

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-21578 REV. 02/2016 Page 2 of 2