Esmolol bolus or no

[WheezyBaby]

Esmolol is a med I need to get more experience with. I know some bolus it, but I'm not sure I see the point given the pharmacodynamics unless 2-3 minutes of titrating really mattered (very tachy with severe CAD, dissection in theory, but would have gotten something else before esmolol available as needs to come from pharmacy). What's your practice?

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[Katheudontas parateroumen]

We definitely like short acting titratable meds in the OR. So esmolol is perfect for sudden stimuli or sympathetic surge such as endotracheal intubation, surgical incision, etc. it’s also nice to use for some tachy arrhythmias just to see if it helps. I don’t always have a full ekg to help just the monitor. It’s short acting enough that it won’t burn many bridges hopefully.

 

[turkeyjerky]

I'm a fan of bolusing it. Otherwise i'ts 10 min or so to reach steady-state, which leads to up to 30-40 mins to really reach max dosing.

We definitely like short acting titratable meds in the OR. So esmolol is perfect for sudden stimuli or sympathetic surge such as endotracheal intubation, surgical incision, etc. it’s also nice to use for some tachy arrhythmias just to see if it helps. I don’t always have a full ekg to help just the monitor. It’s short acting enough that it won’t burn many bridges hopefully.

Do you use it for SVT? I've heard of this but haven't seen any published studies on it. Would be nice to have a faster alternative to diltiazem w/o the fuss and side effects of adenosine.

 

[Katheudontas parateroumen]

I'm a fan of bolusing it. Otherwise i'ts 10 min or so to reach steady-state, which leads to up to 30-40 mins to really reach max dosing.


Do you use it for SVT? I've heard of this but haven't seen any published studies on it. Would be nice to have a faster alternative to diltiazem w/o the fuss and side effects of adenosine.

Yes I use it for SVT as in whatever narrow complex tachy I see on the OR EKG. So it's not a targeted approach by any means but like you said, it's short acting and sometimes does the trick.

 

[deleted547339]

I don’t, but I also work in a medical icu where the need to control things within seconds to minutes is much lower than an OR or surgical icu.

 

[chessknt]

I don't use it because pharmacy tells me it is astronomically expensive. Otherwise it would be a good drug in an ICU setting for rapid titration I imagine.

 

[lymphocyte]

We use it about once a month, either therapeutically or diagnostically.

If we need it therapeutically, we bolus because it's time sensitive (like dissection with active pain).

If we use it diagnostically (like, will they benefit from beta-blockade?), we ONLY bolus and then either switch to metoprolol or abandon the idea.

I've therefore always given a bolus. I would also be curious if anybody does it differently.

 

[jdh71]

I wasn't trained with it and therefore am not terribly facile with it. I'm not sure when and where I'd need it that often in the MICU. I also hate the drips - so much IV fluid "buck" for what has always kind of been a disappointing "bang" on heart rate.

 

[Dred Pirate]

I don't use it because pharmacy tells me it is astronomically expensive. Otherwise it would be a good drug in an ICU setting for rapid titration I imagine.

Really? I am a little removed from drug purchasing, but I have never heard anyone ever tell me this - on the other end of the spectrum - isuprel is stupid expensive, but esmolol for us is reasonable AFAIK

 

[ProwlerturnGas]

When I was in the ICU almost never bolused esmolol, just started the infusion. In the OR, I use it a few times a week in bolus form. Almost never more than 20 mg at a time, it works quickly and I have found that dose lasts about 5-10 minutes. Then titrate from there. If I am looking at longer lasting HR control I use metoprolol.

 

[Steege305]

I'm a fan of bolusing it. Otherwise i'ts 10 min or so to reach steady-state, which leads to up to 30-40 mins to really reach max dosing.


Do you use it for SVT? I've heard of this but haven't seen any published studies on it. Would be nice to have a faster alternative to diltiazem w/o the fuss and side effects of adenosine.

I like to bolus it for younger patients in SVT without significant cardiac dysfunction. I usually give 50mg, wait about 30 seconds, then give the other 50mg. I find that for younger patients smacking them with a lot of beta blocker doesn’t end up with me managing a junctional rhythm. Also, it’s Esmolol, so it’s over quickly.