POISON CONTROL
Death by Procainamide: Medication Errors and Toxicity Caroline Heider, PharmD, PGY-2 Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville
Procainamide is a class 1A antiarrhythmic used for ventricular arrhythmias. A case report by Croskerry and colleagues described an error of communication in transcription for a patient in the emergency department (ED) receiving procainamide for ventricular tachycardia. In this patient case, the intended dose was intravenous (IV) procainamide 100 mg in 10 mL dextrose 5% (D5W) or normal saline (NS). The procainamide formulation supplied in the ED was a vial containing 1000 mg in 10 mL. The nurse withdrew 10 mL of this formulation, for a total of 1000 mg. Prior to administration, the nurse confirmed with the physician that the “whole thing” was to be provided. The physician assumed the prescribed dose of 100 mg in 10 mL was being given, and agreed “yes.” Ultimately, this error led to administration of IV procainamide 1000 mg over three separate instances during the acute resuscitation. The patient subsequently became hemodynamically unstable, was intubated, and died several days later. This is an example of a miscommunication transmitted verbally to expedite medication administration in the high-stress ED environment. Contributing factors noted were unfamiliarity with the drug, time pressures, and low quality transfer of information.1 This product was meant to undergo dilution prior to administration, and the patient ultimately received 10 times the intended procainamide dose.
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The procainamide package insert recommends procainamide as a direct IV injection or IV infusion for lifethreatening ventricular arrhythmias. Direct IV injections of procainamide should be administered at a rate of 100 mg every 5 minutes, up to maximum rate of 50 mg per minute, until the arrhythmia is suppressed or 500 mg has been provided, at which point further doses are to be held for 10 minutes to allow redistribution. IV infusions of procainamide should be administered at 20 mg per minute, for up to 25-30 minutes, to deliver a total of 500-600 mg.2-3 The maximum dose of procainamide for each of these loading dose techniques is 1000 mg. Additionally, the 2020 American Heart Association (AHA) algorithm for Adult Tachycardia with a Pulse recommends IV procainamide for stable wide-QRS complex tachycardia. The AHA recommends procainamide at a rate of 20 to 50 mg per minute until arrhythmia is suppressed, hypotension ensues, QRS duration increases greater than 50%, or a maximum dose of 17 mg per kg is given.4 Furthermore, in the PROCAMIO trial, procainamide was dosed as 10 mg per kg, infused over 20 minutes, for wide-complex tachycardia.5 Although the package insert, AHA guidelines, and the PROCAMIO trial provide guidance for procainamide dosing, these sources do not address the preparation for administration. Procainamide is available as 1000 mg per 10 mL vials (Figure 1) and 1000 mg per 10 mL prefilled syringes (Figure
EMpulse Spring 2021
2).2-3 Both formulations are to be diluted prior to being given in order to facilitate control of the dosage rate, which is 20-50 mg per minute. Dilution may be achieved by placing the 1000 mg per 10 mL concentration in 50 mL to 250 mL of D5W. Procainamide prefilled syringes carry specific marking on the package label stating: “FOR THE PREPARATION OF IV INFUSIONS ONLY.”3 These prefilled syringes are manufactured with a luer lock connector typically associated with direct IV administration. Another medication packaged similarly is epinephrine 1 mg in 10 mL (Figure 3). However, this formulation of epinephrine is intended for direct IV administration and the prefilled syringe of procainamide is not. This procainamide formulation could result
Fig. 1. Procainamide Vial (1000 mg per 10 mL)
