Liverpool Hospital ICU Guideline: Pharmacology Intensive Care Unit

Nimodipine

Drug Guideline Title: Nimodipine

Summary: Nimodipine is used for the prevention and management of cerebral
vasospasm associated with aneurysmal subarachnoid haemorrhage.

Approved by: ICU Director

Publication (Issue) Date: December 2014

Next Review Date: December 2017

Replaces Existing Drug Guideline: Nimodipine

Previous Review Dates: 2003, 2010, 2011

1. Introduction:
The risk addressed by this policy:

Patient Safety

The Aims / Expected Outcome of this policy:

Nimodipine will be administered safely via intravenous infusion and when

clinically indicated weaned to oral administration. Oral nimodipine administration
will be commenced in a timely manner and patients hemodynamic status closely
monitored.

Related Standards or Legislation

NSQHS Standard 1 Governance

National Standard 4 Medication Safety

Related Policies
 LH_PD2013_C03.01 Drug Administration
 LH_PD2010_C03.00 Drug Prescribing
 LH_PD2008_C03.12 Administration of IV Medication
 LH_PD2012_C03.05 Accountable Drugs – Schedule 8 (S8) and S4D
 LH_ICU_Guideline_Care of patient with subarachnoid haemorrhage

2. Policy Statement:
• All care provided within Liverpool Hospital will be in accordance with infection
control, manual handling and minimisation and management of aggression
guidelines.
• Medications are to be prescribed and signed by a medical officer/authorised
nurse practitioner (NP) unless required during an emergency.

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• All drugs administered during an emergency (under the direction of a medical

officer/authorised nurse practitioner) are to be documented during the event,
then prescribed and signed following the event.
• Medications are to be given at the time prescribed (as close to the time as is
possible when multiple drugs require ‘same time’ administration and, when
the nurse is caring for more than one patient, recognition is given to a
possible short delay to administration – antibiotics and other lifesaving drugs
are to be prioritised) and are to be signed by the administering nurse.
• Parenteral medication prescriptions and the drug are to be checked with a
second registered or endorsed enrolled nurse prior to administration. The
“rights of drug administration” must be followed: right: patient, drug, dose,
route, administration, time, reason for the drug, documentation, education
and evaluation/outcome.
• Adverse drug reactions are to be documented and reported to a medical
officer.
• Medication errors are to be reported using the hospital electronic reporting
system: IIMS.
• Guidelines are for adult patients unless otherwise stated
• Use only non-PVC tubing for administration.
• When administering oral nimodipine, ensure the drug is given at the specified
times.
• Ensure that the patient is euvolemic to avoid hypotension post administration
of the oral drug.

3. Principles / Guidelines

Actions1,2,3,16
 Nimodipine is a calcium channel blocker and a cerebrally selective vasodilator.
Its mode of action is thought to include:
 Relaxation of spastic arteries.
 Prevention of vasospasm.
 Opening-up of collateral vessels.
 Protective agent at the neuronal membrane level.
 It may have a preferential cerebral vasodilator action by prevention of calcium
overload in neurons.
 It dilates the small resistance cerebral vessels and increases the cerebral
blood flow, the increased perfusion being generally more pronounced in brain
regions with preliminary damage and restricted circulation than in healthy
regions.
 Nimodipine binds to specific receptor sites in the central nervous system. It
inhibits calcium ion transfer into these cells and inhibits contractions of
vascular smooth muscle.

Indications1,2,3
• Prevention and treatment of delayed ischaemic neurological deficit,
secondary to aneurysmal subarachnoid haemorrhage (SAH).
• Prevention and treatment of cerebral vasospasm associated with aneurysmal
SAH.

Contraindications
• Hypersensitivity.

Precautions1,2,3
• Nimodipine can cause hypotension. If hypertensive therapy is being pursued
or the patient develops significant hypotension during nimodipine treatment,
the dose should be reduced or nimodipine should be withheld.

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Liverpool Hospital ICU Guideline: Pharmacology Intensive Care Unit
Nimodipine

• The metabolism of nimodipine is decreased in patients with impaired hepatic

function. Such patients should have their blood pressure and pulse rate
monitored closely and should be given a lower dose. (usually 50% of normal
dose).

Significant Interactions1,2,3
• IV beta-blockers (can cause negative inotropic effects).
• Rifampicin (reduces effectiveness of nimodipine).
• Grapefruit juice (in oral nimodipine administration) reduces effectiveness of
nimodipine.
• Phenytoin oral dose decreases nimodipine oral bioavailability by 7-fold.
• Sodium valproate oral dose increases the bioavailability of oral nimodipine
dose by 50%.

Adverse Effects1,2,3
• Hypotension, especially in patients with a history of hypertension (10-
20mmHg drop occurs).
• Increased liver enzymes, urea, and creatinine.
• Pseudo-obstruction of the bowel (Ogilvie’s Syndrome).
• Flushing, headache.

Presentation
• Intravenous: 10 mg nimodipine in 50 mL vial
• Oral: 30 mg tablet, yellow, scored

Administration Guidelines1,2,3,13,16
IV infusion
• Draw up contents of vial in a 50ml syringe and prime non-PVC extension
tubing (for administration via a syringe driver).
• Do not dilute.
• Should be administered via a dedicated lumen of a CVAD with a co-infusion.
(May be infused via a peripheral line whilst waiting placement of a triple or
quad-lumen central line).
• Intravenous infusions must have a 3-way tap attached with concomitant
infusion of diluent. Infuse a compatible fluid at a rate of 4 times the nimodipine
infusion rate (1:4):

Dose 0.5 mg/hour 1 mg/hour 2 mg/hour

Nimodipine infusion rate 2.5 mL/hour 5 mL/hour 10 mL/hour

Fluid co-infusion rate 10 mL/hour 20 mL/hour 40 mL/hour
Compatible fluids : Albumin 4%, dextran 40, 5% glucose, Hartmann’s, mannitol
10%, 0.9% sodium chloride.

• Infusions are to be protected from direct sunlight; it is viable for 10 hours in

overhead electric light.

Infusion rate:
• Commence at 15 micrograms/kg/hr (5mL/hr) for the first 1-2 hours, if BP
stable; proceed to recommended dose.
• May need to commence slowly (2.5mL/hr) if patient has decreased BP.
• Recommended dose: 30 micrograms/kg/hr; @ 10mL/hour for 70kg patient.
• Correct fluid imbalance, commence CVP monitoring for trend, volume load as
clinically indicated.
• Maintain MAP and CPP according to pre and post-operative needs; see Care
of patient with SAH guideline.

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Liverpool Hospital ICU Guideline: Pharmacology Intensive Care Unit
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• After 7-10 days IV therapy; no incidence of delayed cerebral ischaemia and

the patient is clinically stable, oral nimodipine may commence.
• All infusion tubing must be changed every 24 hours.

Weaning from IV therapy to oral therapy: Weaning commences when the

first dose of oral therapy is administered.
st
• Administer 1 oral dose of 60mg nimodipine – must be prescribed and
administered at fourth hourly intervals.
• Infusion Weaning: 1 mL every hour for 5 hours, then cease infusion.
• Observe for neurological deterioration (decrease in the GCS or development
of focal deficit: report immediately or as per MET calling criteria).
• If the patient does deteriorate neurologically, cease weaning IV nimodipine
and return to full IV therapy. Obtain medical review and document plan of
care.
• Duration of oral therapy is a minimum of 7 days up to 14 days (may be
extended in the presence of prolonged vasospasm).
• There are no variations on the dosage unless there are significant weight
variances.

Note:
• BP may fall during administration of oral nimodipine, particularly at peak
levels (20 mins post ingestion).
• Urgently notify Intensive Care Registrar if BP less than the prescribed
parameters.
Monitor CVP and BP; ensure adeqaute fluid intake 2-3 litres/day (whether IV or
oral).

Clinical Considerations - Observations during IV therapy

 Monitor vital signs – heart rate and blood pressure continuously during IV
administration.
 Closely monitor GCS and monitor for signs of focal deficit.
 Document hourly GCS, BP, Temp, HR, RR, SpO2, ICP, CPP.
 Vasospasm may be seen angiographically without evidence of clinical
vasospasm. Transcranial Doppler (tcD) sonography may be used to measure
vasospasm.
 Monitor and document hourly fluid balance, daily urinalysis.
 Invasive arterial monitoring should be in place with close observation of set
parameters.
 Daily ECG and prn - if on inotropes / vasopressors.

Observations during oral therapy:

• Second hourly GCS, BP, Temp, HR, RR, Sp02, and BP, required BP
parameters to be prescribed in clinical notes.
th
• Once stable on ward, observations may progress to 4 hourly.
• Strict fluid balance, with intake to total 2-3 litres/day.
• Daily urinalysis.
• Immediately report if blood pressure alters beyond prescribed parameters for
the individual patient.
• Observe for neurological deficits – signs of facial droop, arm or leg weakness;
notify Neurosurgeon urgently.
• Observe for decrease in the level of consciousness; observe MET calling
criteria.
• If patient becomes drowsy and unable to swallow, review MET criteria and
call as appropriate, notify Intensive Care Registrar.

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4. Performance Measures
All incidents are documented using the hospital electronic reporting system:
IIMS and managed appropriately by the NUM and staff as directed.

5. References / Links
1. The Society of Hospital Pharmacists of Australia 2014, The Australian Injectable
th
Drugs Handbook, 6 Edition, SHPA publications, Australia.
2. MIMS Online, CIAP: NSW Health Department, Copyright MIMS Australia Pty Ltd
2014. http://www.mims.hcn.net.au/. http://www.mims.hcn.net.au/
3. eTherapeutic Guidelines: CIAP 2014, http://www.tg.org.au/,
4. Thomas Reuters, Micromedex 2.0, http://www.micromedex.com/, viewed 11th
December 2013.
5. Smith M. 2007. Intensive care management of patients with subarachnoid
haemorrhage. Current Opinion in Anaesthesiology. 20:400-407
6. Suarez JI, Tarr RW & Selman WR. 2006. Aneurysmal subarachnoid hemorrhage.
NEJM. 354(4):387-396. From: www.nejm.org
7. Noble AJ & Schenk T. 2009. Psychosocial outcome following subarachnoid
haemorrhage: an under researched problem. British Journal of Neuroscience
Nursing. 5(8):372-380.
8. Suarez JI. 2006. Outcome in neurocritical care: advances in monitoring and
treatment and effect of a specialized neurocritical care team. Critical Care
Medicine. 34(9) Suppl:S232-S238.
9. St. Julien J, Bandeen-Roche K & Tamargo RJ. 2008. Validation of an aneurismal
subarachnoid hemorrhage grading scale in 1532 consecutive patients.
Neurosurgery. 63(2):204-211.
10. Jones HA. 2009. Arterial transducer placement and cerebral perfusion pressure
monitoring: a discussion. Nursing in Critical Care. 14(6):303-310.
11. Blissitt PA. 2006. Hemodynamic monitoring in the care of the critically ill
neuroscience patient. AACN Advanced Critical Care.17(3):327-340.
12. Singer RJ, Ogilvy CS & Rordorf G. 2014. Treatment of aneurysmal subarachnoid
hemorrhage. From: www.uptodate.com
13. Kronvall E, Undren P, Romner B, Saveland H, Cronqvist M & Nilsson OG. 2009.
Nimodipine in aneurysmal subarachnoid hemorrhage: a randomized study of
intravenous or peroral administration. Journal of Neurosurgery. 110(1):58-63.
14. Devlin MM. 2008. Nimodipine: test your drug IQ. Nursing. 37(7):56cc1-2.
15. Keyrouz SG and Diringer MN. 2007. Clinical review: Prevention and therapy of
vasospasm in subarachnoid hemorrhage. Critical Care. 11(4):220.
16. Dorhout Mees SM., Rinkel GJ., Feigin VL., Algra A., Van Den Bergh WM.,
Vermeulen M. & Van Gijn J. 2007. Calcium antagonists for aneurysmal
subarachnoid haemorrhage. Update of Cochrane Database Syst Rev.
2005;(1):CD000277; PMID: 15674871. Cochrane Database of Systematic
Reviews. (3):CD000277.

Author: RN ICU (Y. McManus), CNC – ICU (S. Shunker);

Reviewers: ICU – CNC, CNE, NM, NUM, Staff Specialists, CNS ‘s, Medical
Director, Pharmacist
Endorsed by: A/ Prof M. Parr, Director ICU.

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