Unique Plan Description: Arrhythmia [EBM] (FH)
Plan Selection Display: Arrhythmia [EBM] (FH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-04-19 11:56:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-02-14 14:11:39
Available at all facilities: Yes

Arrhythmia [EBM] (FH)
Laboratory
Chemistry
		During follow-up, serum creatinine, potassium, and magnesium concentrations should be monitored periodically because proarrhythmia is increased by renal insufficiency, which can lead to drug accumulation, hyperkalemia, and hypermagnesemia. The presence of(NOTE)*
	Renal Function Panel
		T;N, Routine, spec type = Blood
	TSH
		T;N, Routine, spec type = Blood
	Free T4
		T;N, Routine, spec type = Blood
	Magnesium Level
		Timed, spec type = Blood
		T;N, Routine, spec type = Blood
		T+1;0500, Routine, spec type = Blood
Therapeutic Drug Levels
	Cordarone Level
		T;N, Routine, spec type = Blood
	Digoxin Level
		T;N, Routine, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Q24H, Timed, spec type = Diagnostic Blood
		T;N, Q24H, Timed, spec type = Therapeutic Blood
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
		T;N, Routine, spec type = Diagnostic Blood
		T;N, Routine, spec type = Therapeutic Blood
Diagnostic Tests

	EKG (ECG)
		T;N, Stat
		T;N, Routine, DAILY, 3, Day(s)
IV Solutions
	diltiazem 100 mg/NS 100 mL (FH)
		100 mg, EVERY BAG, 10 mg/hr
		100 mL, IV, Routine, Start: T;N, Maintain Parameter Goal: HR< 100, Increment Increase: 5 mg/hr, Increment Decrease: 5 mg/hr, Increment Freq: 15 min(s), Max Dose: 15 mg/hr
			Comment: ACTIVATION REQUIRED PRIOR TO USE.  increase infusion to 15mg/hr if heart rate greater than or equal to 120 after second bolus.  . Discontinue Diltiazem infusion 1 hour after oral dose initiated.  Begin  Tiazac 180 mg po when HR rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 5mg/hr. Begin Tiazac 240 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 10 mg/h.  Begin Tiazac 300 mg po when heart rate has been less than 100 bpm for 4 hours, and or sinus rhythm has returned, if infusion rate 15 mg/hr.  Enter oral diltiazem order from Acute Atrial Fibrillation Powerplan.
	amiodarone 360mg/D5W 200mL Premix IV
		360 mg, EVERY BAG, 1 mg/min, T;N
		200 mL, IV, Routine, T;N
			Comment: 1 mg/min (33ml/hr) for 6hr (200mL) then 0.5 mg/min (16.7ml/hr) continuous
	amiodarone IV Push
		150 mg, Injection, IV Push, Once, STAT
Medications
		For patients with heart failure, UpToDate suggests amiodarone in preference to dofetilide (Grade 2B). Flecainide, propafenone, dronedarone, and sotalol are contraindicated in these patients.(NOTE)*
		Simvastatin in combination with amiodarone has been associated with reports of myopathy/rhabdomyolysis. Therefore, the dose of simvastatin should not exceed 20 mg/day.(NOTE)*
		For Tikosyn (dofetilide); order separate OS once done with this Power Plan(NOTE)*
	propafenone
		150 mg, Tab, By Mouth, Q8H
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	flecainide
		50 mg, Tab, By Mouth, BID
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
		100 mg, Tab, By Mouth, BID
			Comment: Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	sotalol
		80 mg, Tab, By Mouth, BID
			Comment: CrCl >60 mL/min Continuous Tele for 5 doses.  Ensure Daily EKG X3 qAM after morning doses.
	amiodarone
		200 mg, Tab, By Mouth, BID
		100 mg, Tab, By Mouth, BID
		Beta blockers are modestly effective in maintaining sinus rhythm and can be tried first in selected patients, such as those without structural heart disease who are concerned about proarrhythmia.(NOTE)*
		Maintenance antiarrhythmic drug therapy is not recommended after cardioversion in a patient with a transient or reversible cause (such as cardiac surgery, pericarditis, or pulmonary embolism). An option in such patients is beta blocker therapy after resto(NOTE)*
	Lopressor
		5 mg, Solution-Injection, IV Push, Q6H
			Comment: Hold for SBP<100 or HR <60
		5 mg, Solution-Injection, IV Push, Once, T;N
			Comment: Hold for SBP<100 or HR <60
	metoprolol TARTRATE
		12.5 mg, Tab, By Mouth, BID
		25 mg, Tab, By Mouth, BID
		50 mg, Tab, By Mouth, BID
		100 mg, Tab, By Mouth, BID
	metoprolol SUCCINATE
		25 mg, Tablet-Extended-Release, By Mouth, DAILY
		50 mg, Tablet-Extended-Release, By Mouth, DAILY
	atenolol
		25 mg, Tab, By Mouth, DAILY
	nadolol
		40 mg, Tab, By Mouth, DAILY
	propranolol
		10 mg, Tab, By Mouth, BID
		20 mg, Tab, By Mouth, BID
		10 mg, Tab, By Mouth, TID
		20 mg, Tab, By Mouth, TID
	verapamil
		40 mg, Tab, By Mouth, TID
		80 mg, Tab, By Mouth, TID
		120 mg, Capsule-Extended-Release, By Mouth, DAILY
		180 mg, Tablet-Extended-Release, By Mouth, DAILY
		240 mg, Capsule-Extended-Release, By Mouth, DAILY
	dilTIAZem
		30 mg, Tab, By Mouth, QID
	diltiazem  ER
		120 mg, Capsule-Extended-Release, By Mouth, DAILY
		180 mg, Capsule-Extended-Release, By Mouth, DAILY
		240 mg, Capsule-Extended-Release, By Mouth, DAILY
		300 mg, Capsule-Extended-Release, By Mouth, DAILY
	Cardizem
		0.25 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate >/= 120bpm, for 20 minutes. Give over 2 minutes, then begin diltiazem infusion at 10mg/hr. Max dose 20mg
		0.35 mg/kg, Injection, IV Push, Once, PRN see comment
			Comment: PRN heart rate > 120bpm 30 min after 1st bolus given. Give over 2 minutes, if heart rate greater than 120 bpm after bolus, increase infusion to 15mg/hr.  Max dose 25mg
		Digoxin is often used in patients with AF associated with systolic heart failure because of its beneficial effect on symptom control.(NOTE)*
		CrCl 10 to 50 mL/min: 25% to 75% of the normal dose or usual dose every 36 hours CrCl less than 10 mL/min or hemodialysis: 10% to 25% of the normal dose or usual dose every 48 hours(NOTE)*
	digoxin
		125 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		250 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		500 mcg, Injection, IV Push, Q4H, duration: 3 Dose(s)/Time(s)
		0.125 mg, Tab, By Mouth, DAILY
		0.0625 mg, Tab, By Mouth, DAILY
		0.25 mg, Tab, By Mouth, DAILY
		Chronic anticoagulation is required with either rhythm or rate control in most patients. An exception to this need for maintenance anticoagulation occurs in patients without structural heart disease who are at low risk for embolization; such patients can(NOTE)*
		However, anticoagulation is required for at least three weeks prior to, during, and for at least four weeks after cardioversion in patients with AF duration of longer than 48 hours. After four weeks of anticoagulation, individuals who do not require long-(NOTE)*
	dabigatran
		75 mg, Capsule, By Mouth, BID
		150 mg, Capsule, By Mouth, BID
	warfarin
		2.5 mg, Tab, By Mouth, DAILY
		5 mg, Tab, By Mouth, DAILY
		7.5 mg, Tab, By Mouth, DAILY
	aspirin
		325 mg, Tab, By Mouth, DAILY
	rivaroxaban
		15 mg, Tab, By Mouth, DAILYW/SUPPER
		20 mg, Tab, By Mouth, DAILYW/SUPPER
	apixaban
		2.5 mg, Tab, By Mouth, BID
		5 mg, Tab, By Mouth, BID
	enoxaparin
		1 mg/kg, Syringe, SUBCUTANEOUS, BID
		1.5 mg/kg, Syringe, SUBCUTANEOUS, BID
Patient Care
	Cardiac Telemetry Monitoring
		Monitor patient closely for: lethal arrhythmias, Torsades de pointes, V-fib, Bradycardia, Heart block, Hypotension
	Pulse Oximetry Spot Check by nurse
		
	Patient Education
		T;N, Instructions: arrhythmias related teaching
	Anticoagulation Education
		T;N
Consults/Follow-up
	Consult Cardiologist

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase