Parenteral Manual

Bretylium tosylate

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
BRETYLATE®
Classification: 
Antiarrhythmic
Original Date: 
August 2005
Revised Date: 
September 2011
Indications: 
  • Ventricular arrhythmias, principally ventricular fibrillation and ventricular tachycardia which have failed to respond to first-line antiarrhythmic agents
  • Bretylium has been removed from the 2000 ACLS and PALS Guidelines due to high incidence of adverse drug reactions (e.g., hypotension) and availability of safer agents.
Reconstitution and Stability: 
  • Available as 50 mg/mL solution
  • Stable at room temperature
Compatibility: 

- Solutions Compatible:  D5W, NS, D5W-saline combinations, ringer's lactate

- Additives/Above Cassette Compatible: KCl (up to 40 mmol/L)

-Y-site Compatible: no information

Incompatible: warfarin, propofol, amphotericin B cholesteryl sulfate complex

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC NO
IM

YES- Not recommended for ventricular fibrillation.

Vary sites of injection to avoid muscular or vascular tissue damage
Usual dilution: undiluted, maximum 5 mL/site
IV Direct

YES, critical care areas only, physician present, life-threatening situations
Usual dilution: undiluted (50 mg/mL)
Infusion time: 1 minute
IV Intermittent Infusion YES, critical care areas only
Usual dilution: 10 mg/mL
Infusion time: 10-15 minutes
IV Continuous Infusion YES, critical care areas only
Usual dilution: 2 mg/mL
Infusion rate: 1-2 mg/minute
Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

PEDIATRIC:               

  • Initial: 2-5 mg/kg IM as a single dose (not route recommended for ventricular fibrillation)
              5 mg/kg/dose IV, may repeat 10-20 minutes PRN for a maximum total dose of 30 mg/kg
  • Ventricular fibrillation: 5 mg/kg/dose IV, then attempt electrical defibrillation; may repeat with 2 more doses of 10 mg/kg 10-20 minutes apart
  • Maintenance: 5 mg/kg IM or IV every 6-8 hours (maximum dose: 40 mg/kg/day)

ADOLESCENT/ADULT:         

  • Life-threatening: 5 mg/kg undiluted by IV push over 1 minute
    •  dosage may be increased to 10 mg/kg and repeated at 15-30 min. intervals until a total dose of not more than 30-35 mg/kg has been given
  • Non-acute ventricular arrhythmias: 5-10 mg/kg/dose IM or IV, may repeat Q 1-2 hours; give IV dose diluted in D5W or NS over 8-10 minutes
  • Maintenance: 5-10 mg/kg IM or IV intermittent every 6-8 hours, or 1-2 mg/minute by IV continuous infusion (Maximum: 40 mg/kg/day)

DOSING ADJUSTMENT IN RENAL IMPAIRMENT:

  • CrCl  10-50 mL/minute:  25-50% of normal dose
  • CrCl  < 10 mL/minute:  25% of normal dose or choose an alternative agent
Potential hazards of parenteral administration: 
  • Hypotension or transient hypertension and increased ventricular arrhythmias, bradycardia, syncope
  • Severe nausea and vomiting especially with too rapid IV
  • Facial and conjunctival flushing with rapid IV injection
  • Transient pain and necrosis at injection sites - avoid extravasation
  •  Vertigo, confusion, anxiety
  • Renal impairment
Notes: 
  • Repeated IM injections may cause tissue necrosis (rotate sites of injection)
  • Requires continuous hemodynamic monitoring (i.e. ECG, heart rate, BP, heart rhythm)
  • Because of unpredictable hypotension, patients should be recumbent throughout treatment
  • Caution in patients with sinus bradycardia
  • Caution when used in combination with other antiarrhythmics (hypotension)
  • Should not be used for arrhythmias secondary to digitalis toxicity
  • Onset  IM: up to 2 hours; IV: within 6-20 minutes

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