PROCAINAMIDE HCI (Pronestyl)

• useful in supraventricular and ventricular tachycardias
• may be useful when lidocaine is ineffective 
• undergoes hepatic metabolism to active metabolite, N-acetyl-procainamide (NAPA)

• Bolus:
  • 100mg IV direct q5 minutes to a maximum of 1 g then maintenance infusion 2 - 6mg/min
• or
  • 17mg/kg IV direct as loading dose followed by maintenance infusion 2.8mg/kg/hour

dose must be reduced in renal failure to maintenance infusion 1.4mg/kg/hour

• IV Direct:
  • administration rate should not exceed 25-50 mg/min
• IV Infusion:
  • 2g/500mL dextrose 5% or sodium chloride 0.9%

• yellow discoloration is acceptable; dark amber solutions should be discarded

• Cardiac:
  • arrhythmias: ventricular tachycardia or fibrillation, Torsades de Pointes (associated with high levels of procainamide and/or NAPA; secondary to prolonged QT interval)
  • heart block
  • prolongation of PR, QRS, QT intervals (up to 50%)
  • bradycardia, asystole
  • decreased BP, decreased CO
• Immunologic:
  • lupus erythematosus like syndrome
  • fever
  • neutropenia, agranulocytosis, thrombocytopenia
• Others:
  • peripheral neuropathy

• myasthenia gravis
• in complete heart block or type II second degree heart block unless functional pacemaker in place (can suppress a ventricular escape rhythm)
• following electrical conversion

• procainamide + amiodarone = increased plasma procainamide concentration
• procainamide + cimetidine = increased plasma procainamide concentration
• procainamide + lidocaine = increased CNS toxicity
• procainamide + neuromuscular blockers = increased neuromuscular blockade

• continuous heart rate and rhythm
• PR, QRS, QT widening by 50%
• blood pressure
• urine output
• CBC, platelets

procainamide serum level: therapeutic: 17-68 uM/L (pre-dose)

procainamide + NAPA serum level:  therapeutic: 43-128 uM/L (pre-dose)

• May be administered IV direct or by IV infusion by a nurse in Adult Critical Care
• Continuous infusions must be administered by infusion device and the pump library must be enabled
• May be titrated to ECG rhythm by a nurse in Adult Critical Care