[Music] all right in today's lesson we are going to be talking about diltiazam also known as cardizem so as usual let's start off with just a quick history and background here i actually don't have a whole lot of background information on this medication pretty much essentially it was initially approved by the fda for use in 1982 and it is available as a generic drug so definitely is one that is going to be commonly used because of that all right so now on to more about this medication so diltiazem or cartazam it is a calcium channel blocker that blocks the calcium channels both in the heart as well as blood vessels all right so for our therapeutic action so first and foremost you know like i said it blocks those calcium channels and the heart and the blood vessels and it does this by inhibiting the influx of extracellular calcium ions across either the myocardial or vascular smooth muscle cell membranes during that depolarization so you can think here we're having an effect on the action potential so as a result of this it actually ends up having a negative inotropic effect so here think less contractility as well as a negative chronotropic effect and so it's going to slow the heart rate and the way it does this is it actually has a very strong negative effect on the conduction of the av node now the reduced intracellular calcium concentrations also equates to increased smooth muscle relaxation which then results in arterial vasodilation which does also include the coronary arteries and thus a decreased blood pressure so all that said though uh cardosim does have a stronger effect on the cardiac calcium channels as opposed to the vascular ones so this is going to kind of be opposite of something like nicardipine or cardine which also is a calcium channel blocker but that one is actually almost primarily selective for vascular smooth muscle so that said cardine does potentially have an effect on blood pressure but its primary use is going to be related to those cardiac effects so since we're talking about that let's talk about some of the indications that we have so like i said the the first and primary way that we're going to be using this is for cardiac dysrhythmias to control a rapid ventricular rate so here think patients that are in a flutter afib as well as proximal supraventricular tachycardia it is classified as a class 4 antiarrhythmic all right another indication is for hypertension and it can be used alone or in combination with other antihypertensives but that said the the strength of the antihypertensive effect is really going to be relative to the patient's blood pressure so what this means is that a hypertensive patient is going to have a greater anti-hypertensive effect than a normal tensive patient would and then finally we can use this medication to manage so either prinz metal or other types of chronic stable angina so prinn's mental angina also known as vasospastic angina is actually a rare but sometimes severe type of angina that typically happens overnight while you're resting or sleeping that said carter sim is potentially an option to treat these patients here all right so now let's talk about some of our contraindications so obviously hypersensitivity to the drug would be a contraindication we don't want to use this for patients with sick sinus syndrome as well as those that have either second or third degree av blocks that don't currently have a pacemaker implanted hypotension is going to be another contraindication we don't want to make that worse acute myocardial infarction pulmonary congestion um we do want to use this cautiously though in in older adults that have a heart failure hypertrophic obstructive cardiomyopathies or impaired hepatic or renal function now some contraindications that are relative to the iv dose would be in cardiogenic shock ventricular tachycardia as well as in conjunction with a recent iv beta blocker therapy and then finally in patients that have wolve parkinson white syndrome this may paradoxically increase the ventricular rate due to that accessory conduction pathway and so those patients that have wolf parkinson white syndrome and they actually have the abnormal heartbeat due to having that extra electrical pathway that kind of parallels the av node and this can result in some pretty rapid heart rate sometimes all right so some adverse effects of this medication we do want to watch for headaches and dizziness arrhythmias av blocks bradycardia heart failure hypotension but with all these uh this medication is more likely to exacerbate existing cardiac dysfunction nausea and constipation are other potential adverse effects and it may also cause a chronic rash in elderly patients but this is also similar for other calcium channel blockers as well all right so on to our common concentrations that we're going to see this medication in when we're giving this iv push typically we're going to find this in 5 milligrams per ml and this is often available in either 5 10 or 25 ml vials these do not need diluting before we give them when it comes to a continuous infusion we're typically going to find this in 125 milligrams and 125 ml of either d5 water or d5 half and s now for our common dosing so we do have po dosing that is potentially something that you know you'll have patients on and you'll be given this medication and this dose really just varies greatly depending on the patient's particular response and where they're at with the medication for our iv infusions though we're going to be giving this medication at a rate of anywhere from five to a max of 15 milligrams per hour now when we do start this we often start it with an initial iv bolus and typically this is going to be 0.25 milligrams per kilogram over about 2 minutes that said we can give 0.35 milligrams per kilogram after about 15 minutes if that first bolus dose is ineffective now for the initial rate that we start these patients off it's pretty common that we're going to start it off at 10 milligrams per hour following that bolus dose and then we really want to titrate it to maintain either a goal heart rate or potentially gold blood pressure if that's what we're using it for this medication though shouldn't be used any longer than 24 hours all right for our pharmacokinetics when we're giving this medication iv the onset is is pretty rapid but definitely less than two to three minutes has a peak in about two to seven minutes and the duration can last anywhere from one to ten hours or obviously the duration of the infusion so cartosim is metabolized extensively during the first pass through the liver and then does undergo nearly complete metabolism prior to being excreted in the urine and feces and there is no antidote for this medication all right so let's finally move on and talk about some of our nursing considerations when we have patients on this medication so obviously we want to be monitoring our patients blood pressure and heart rate especially when we're starting the therapy as well as during all the different dose adjustments so the patient should be on a continuous ecg monitor and have pretty frequent blood pressure readings going off we do also want to have periodic 12 lead ecgs that should be performed as well do withhold the dose and then notify the provider if your systolic blood pressure is less than 90 or you have a heart rate that's less than 60 and this medication can intensify the cardio suppressant effects of the beta blockers especially when they're taken in conjunction and then lastly we do want to have the patient avoid grapefruit juice as it can significantly increase the levels of diltiazem and then finally for some relevant lab studies really the main thing is that we do want to make sure that we're checking our patients liver and renal functioning this medication can cause acute hepatic injury and so it may increase either our alt ast ldh uh bilirubin or potentially the alkavas so definitely things we want to be monitoring and that was our review of diltiazem kardasim i hope you guys enjoyed it so i hope that you guys found this information useful if you did please leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a comment down below i love reading the comments that you guys leave and i try to respond to as many people as i can make sure you subscribe to this channel if you haven't already and a special shout out to the awesome youtube and patreon members out there the support that you're willing to show me and this channel is truly appreciated so thank you guys so very much if you'd be interested in showing additional support for this channel you can find links to both the youtube and patreon membership down below head on over there and check out some of the perks that you guys get for doing just that as well as check out some of the links to other nursing gear as well as some awesome 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