In controlled clinical trials, therapy with antiarrhythmic agents to maintain reduced heart rate in atrial fibrillation or atrial flutter or for prophylaxis of PSVT was generally started within 3 hours after bolus administration of diltiazem hydrochloride injection. The average heart rate is reduced by 20%. An extremely severe case of cutaneous calcinosis with juvenile dermatomyositis, and successful treatment with diltiazem. Reduction in mean arterial pressure correlated linearly with diltiazem plasma concentration in a group of hypertensive patients. Buspirone - In nine healthy subjects, diltiazem significantly increased the mean buspirone AUC 5.5 fold and Cmax 4.1 fold compared to placebo. - Secure the cannula during the administration of the drug. 42, 48 In two cases of TPN extravasation, 25 units of hyaluronidase were injected intradermally around the inflamed area, resulting in clinical improvement within 6-12 hours. These doses, in some studies, have been reported to cause skeletal abnormalities. information and will only use or disclose that information as set forth in our notice of include protected health information. 2737 0 obj <> endobj The sample was 18 healthy adults between 20 and 45 years. The risk of myopathy and rhabdomyolysis with statins metabolized by CYP3A4 may be increased with concomitant use of diltiazem. Common non-antineoplastic drugs that can act as vesicants or irritants [Internet] [cited 2020 Jul 10]. Antidotes for the care of the extravasation. Narcotic analgesics may be required to reduce severe pain around widespread extensive necrosis. f8.5$_t_ htt_t_ htu 8|?f|o_xR}A)xcw{|YwO]oz46Qm` QOSi p"e3b9Ez1xr&(^L{/s<<1XW^YQIN2MZ_t_ htt_t_ htu?D_sunm5]BZ>,t vncs; xF,~kjM+`}h_. Administration of oral diltiazem in patients with acute myocardial infarction and pulmonary congestion documented by x-ray on admission is contraindicated. To prevent extravasation, a clinical specialist should perform the venipuncture or injection, who with relevant skills and management ability understands the properties of the injected drug. 2.5-3.6 Extravasation: may cause tissue damage Do not flush Albumin 4.5% Infusion Normal blood volume: 1-2ml/min Hypovolaemia or shock: up to 1 L/hour Plasma exchange: up to This relaxes the blood vessels, lowers blood pressure, and increases the supply of blood and oxygen to the heart while reducing its workload. 125 mg per 25 mL (5 mg/mL) Pediatric Use Do NOT flush the line with normal saline or dextrose It has no effect on the sinus node recovery time or on the sinoatrial conduction time in patients without SA nodal dysfunction. 0000029746 00000 n It has a molecular weight of 451.0. It is the brilliant info like a diamond that is useful for the training of the interns, nurses, and medical laboratory technicians who routinely work for the vascular injection. Diltiazem can pass into breast milk and may harm a nursing baby. Diltiazem hydrochloride injection is clear, colorless, sterile, nonpyrogenic solution and is supplied as follows: Metoprolol Cold Hydrocortisone 50-200 mg Give via 5-10 SQ or TD injections into area of extravasation Medication Thermal Therapy Antidote Dose Treatment Nitroglycerin Cold Hydrocortisone 50-200 mg Give via 5-10 SQ or TD injections into area of extravasation Norepinephrine Heat Nitroglycerin 2% paste n/a Apply thin layer to area of extravasation q 6 hr x 24 hr However, reference should be made to the respective agent manufacturer's package insert for information relative to dosage and administration. The use of local warming therapy (dry heat) is based on the theory that it enhances vasodilation, thus enhancing the dispersion of the vesicant agent and decreasing drug accumulation in the local tissue. Do not freeze. Norwood (MA). Sodium hydroxide or hydrochloric acid is used for pH adjustment. the contents by NLM or the National Institutes of Health. This content does not have an English version. To provide you with the most relevant and helpful information, and understand which Diltiazem is not intended to convert atrial fib or flutter to NSR but to slow the heart rate down. With the practical use of these guidelines, it is expected to reduce the occurrence rate of extravasation and contribute to patient care improvement. - Dilute stimulant drugs as much as possible and inject them at a proper rate. In patients with atrial fibrillation and atrial flutter, a significant correlation was observed between the percent reduction in HR and plasma diltiazem concentration using the Sigmoidal Emax model. In subgroup analysis following a two-dose procedure in double-blind and open-label studies, 104 patients 65 years of age and 95 patients <65 both had a 95% response rate. HCl Injection 25-mg, 5-mL vialeach sterile vial contains 25 mg diltiazem hydrochloride, 3.75 mg citric acid USP, 3.25 mg sodium citrate dihydrate USP, 357 mg sorbitol solution USP, and water for injection USP up to 5 mL. As such, the initial use of diltiazem hydrochloride injection should be, if possible, in a setting where monitoring and resuscitation capabilities, including DC cardioversion/defibrillation, are present (see OVERDOSAGE). Patients with ventricular tachycardia. - If in doubt, re-insert the cannula and administer the drug. Diltiazem In patients with cardiovascular disease, diltiazem hydrochloride injection administered intravenously in single bolus doses, followed in some cases by a continuous infusion, reduced blood pressure, systemic vascular resistance, the rate-pressure product, and coronary vascular resistance and increased coronary blood flow. Careers. Supplement 6. Unauthorized use of these marks is strictly prohibited. Use diltiazem regularly to get the most benefit. If response is inadequate, a second dose may be administered after 15 minutes. 7. 0.5 - 1 mL over 1 minute. Diltiazem (Cardizem, Tiazac, others) Felodipine; Isradipine; Nicardipine; Nifedipine (Procardia) Nisoldipine (Sular) Verapamil (Calan SR, Verelan) Sometimes, a doctor might prescribe a calcium channel blocker with other high blood pressure medications or with cholesterol-lowering drugs such as statins. Diltiazem is in a class of medications called calcium-channel blockers. No potential conflict of interest relevant to this article was reported. 0000003491 00000 n Medically reviewed by Drugs.com. Patients currently receiving diltiazem therapy should be carefully monitored for a change in pharmacological effect when initiating and discontinuing therapy with cimetidine. Injection and Continuous Pharmacologic interventions for extravasation Call your doctor for medical advice about side effects. 3. Prompt interdisciplinary action is often necessary for the treatment of extravasation injuries. In renal and cardiac transplant recipients, a reduction of cyclosporine dose ranging from 15% to 48% was necessary to maintain cyclosporine trough concentrations similar to those seen prior to the addition of diltiazem. I remember the case of the complication of extravasation in my patient in 1985 when I was an intern. Pain or tightening occurs along the vein, and it is caused mainly by drugs such as vinorelbine and dacarbazine. 364 0 obj <>stream These problems may be less likely to occur if blood pressure is controlled. Available for Android and iOS devices. Cold application is recommended for extravasation of DNA-binding vesicants except for mechlorethamine (nitrogen mustard), contrast media, and hyperosmolar fluids. This content does not have an Arabic version. As with other agents which slow AV nodal conduction and do not prolong the refractoriness of the accessory pathway (e.g., verapamil, digoxin), in rare instances patients in atrial fibrillation or atrial flutter associated with an accessory bypass tract may experience a potentially life-threatening increase in heart rate accompanied by hypotension when treated with diltiazem hydrochloride injection. Diltiazem prolongs the sinus cycle length. In the same study, there was no significant change in 20 mg single dose pravastatin AUC and Cmax during diltiazem coadministration. The prolongation of PR interval correlated significantly with plasma diltiazem concentration in normal volunteers using the Sigmoidal Emax model. Following administration of one or two intravenous bolus doses of diltiazem hydrochloride injection, response usually occurs within 3 minutes and maximal heart rate reduction generally occurs in 2 to 7 minutes. - Edema around the port insertion or in the chest, or medication leakage around the catheter insertion, - Redness in the chest, collarbone, or neck where a central venous catheter is inserted. Patients must be informed to report any changes in sensation, signs, or symptoms during the IV administration of any chemotherapeutic drug and to alert the healthcare professionals to early signs of extravasation. Mix thoroughly. Data files are available from Harvard Dataverse: https://doi.org/10.7910/DVN/NUWZML. Rifampin - Coadministration of rifampin with diltiazem lowered the diltiazem plasma concentrations to undetectable levels. Following single intravenous injection of diltiazem hydrochloride, however, plasma concentrations of N-monodesmethyldiltiazem and desacetyldiltiazem, two principal metabolites found in plasma after oral administration, are typically not detected. 8th ed. BIT Druginfo website [Internet] [cited 2020 Jul 10]. Herein, general knowledge about extravasation is first described, including its definition, incidence, risk factors, diagnosis, differential diagnosis, and extravasation injuries. 113. Direct Intravenous Single Injections (Bolus) Heart rate reduction may last from 1 to 3 hours. Bradycardia: Administer atropine (0.6 to 1.0 mg). Local thermal treatments are used to decrease the site reaction and absorption of the infiltrate. These two medications are different than other calcium channel blockers because they have direct action on cardiac tissue at therapeutic levels. privacy practices. 549 0 obj <>stream Visualization: JTK, JYP, HJL, YJC. Before Cyclosporine - A pharmacokinetic interaction between diltiazem and cyclosporine has been observed during studies involving renal and cardiac transplant patients. The phase IV clinical study analyzes which people take Cardizem and have Injection site extravasation. The following measures may be considered: Patients should be monitored for signs of hypercalcemia. The audio recording of the abstract. If you are being treated for high blood pressure, keep using this medicine even if you feel well. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. The guidelines described herein are based on the authors best practice for the management and prevention of the extravasation. 0000019842 00000 n No report of Extravasation is found in people who take Diltiazem hydrochloride. Store product under refrigeration 2 to 8C (36 to 46F). If bone marrow function decreases, anticancer treatments may be delayed due to infection caused by leukopenia. Diltiazem May repeat with 2. nd LD = 0.25 mg/kg over 2 min. Nursing standard for intravenous injection of Asan Medical Center. 0000003528 00000 n $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ? 125-mg, 25-mL vialeach sterile vial contains 125 mg diltiazem hydrochloride, 18.75 mg citric acid USP, 16.25 mg sodium citrate dihydrate USP, 1,785 mg sorbitol solution USP, and water for injection USP up to 25 mL. If possible, it is recommended that diltiazem hydrochloride injection not be co-infused in the same intravenous line. - Veins on the back of the hand can be used, and in some cases, observation is easier. The infusion rate may be increased in 5 mg/h increments up to 15 mg/h as needed, if further reduction in heart rate is required. Over this infusion range, as the dose is increased, systemic clearance decreases from 64 to 48 L/h while the plasma elimination half-life increases from 4.1 to 4.9 hours. Dosage: The dose is 150 units (1 mL) given as five 0.2 mL injections into the extravasation site at the leading edge; change the needle after each injection. Your doctor will adjust the dose and frequency of diltiazem to your needs. 113. The effectiveness of intravenous calcium administration to reverse the pharmacological effects of diltiazem overdose has been inconsistent. 10 mL Single-Dose Vials Herein, general knowledge about extravasation is first described, including its definition, incidence, risk factors, diagnosis, differential diagnosis, and extravasation injuries. Diltiazem hydrochloride is extensively metabolized by the liver and excreted by the kidneys and in bile. You may need to use blood pressure medicine for the rest of your life. The use of vasopressor medications is the mainstay in management of patients with distributive shock in intensive care unit (ICU). Extravasation is a serious complication during patient care. For Direct Intravenous Bolus Injection and Acute Hepatic Injury - In rare instances, significant elevations in enzymes such as alkaline phosphatase, LDH, SGOT, SGPT, and other phenomena consistent with acute hepatic injury have been noted following oral diltiazem. Please read our disclaimer. Copyright 1996-2023 Cerner Multum, Inc. Drug Interactions Discard Unused Portion Store Under Refrigeration In addition, caution should be used in patients taking other drugs that decrease peripheral resistance, intravascular volume, myocardial contractility or conduction. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. As with all drugs, care should be exercised when treating patients with multiple medications. The .gov means its official. Destroy after 1 month at room temperature. Discard Unused Portion Store Under Refrigeration Calcium gluconate has also been administered as a continuous infusion at a rate of 2 g per hour for 10 hours. Extravasation severity can range from benign lipid masses to florid skin necrosis. Regression of calcinosis associated with adult dermatomyositis following diltiazem therapy. An adjustment in the diltiazem dose may be warranted. information submitted for this request. It is soluble in water, methanol, and chloroform. This site needs JavaScript to work properly. Sterile 5 mL Single-Dose Vial, Rx only NDC 55150-425-10 But it must be done carefully because this area can suffer a more severe injury due to extravasation. While the injury is usually minor and resolves spontaneously, some cases result in serious complications, including full-thickness skin loss and muscle and tendon necrosis requiring reconstructive surgery or even amputation, leading to longer hospital stays, increased morbidity, and increased costs. Federal government websites often end in .gov or .mil. In a healthy volunteer cross-over study (N=10), coadministration of a single 20 mg dose of simvastatin at the end of a 14 day regimen with 120 mg BID diltiazem SR resulted in a 5-fold increase in mean simvastatin AUC versus simvastatin alone. Fixed high-degree AV block should be treated with cardiac pacing. Management of extravasation includes nursing intervention and thermal application. Atrial fibrillation or atrial flutter - In clinical studies with diltiazem hydrochloride injection for AF/FI, 135 of 257 patients were 65 years of age. Hudson (OH): Lexi-Comp Inc; 2000. When used concomitantly, anesthetics and calcium blockers should be titrated carefully. The average age of the children in this study was about 3 years. Cardiac Failure: Administer inotropic agents (isoproterenol, dopamine, or dobutamine) and diuretics. Available from: De Wit M, Ortner P, Lipp HP, Sehouli J, Untch M, Ruhnke M, Mayer-Steinacker R, Bokemeyer C, Jordan K. Management of cytotoxic extravasation: ASORS expert opinion for diagnosis, prevention and treatment. It works by relaxing the blood vessels so the heart does not have to pump as hard. INTRODUCTION. Patients who have demonstrated hypersensitivity to the drug. The site is secure. The usual dose range of oral diltiazem for the treatment of hypertension is 180 to 360 mg daily. Compatibility: Diltiazem hydrochloride injection was tested for compatibility with three commonly used intravenous fluids at a maximal concentration of 1 mg diltiazem hydrochloride per milliliter. If we combine this information with your protected IV infiltrations and extravasations occur when fluid leaks out of the vein into surrounding soft tissue. Adverse events reported in controlled and uncontrolled clinical trials were generally mild and transient. Carcinogenesis, Mutagenesis, Impairment of Fertility, Paroxysmal supraventricular tachycardia -, Direct Intravenous Single Injections (Bolus), Quantity of Diltiazem hydrochloride injection, Transition to Further Antiarrhythmic Therapy, diltiazem hydrochloride injection, solution. A defibrillator and emergency equipment should be readily available. For prevention of extravasation, health professionals should be familiar with the extravasation management standard guidelines. The drug should be used with caution in patients with impaired renal or hepatic function (see WARNINGS). Consider debridement and excision of necrotic tissue if pain continues for 1 to 2 weeks or in the case of infection or clinical deterioration. Local thermal treatments are used to decrease the site reaction and absorption of the infiltrate. High blood pressure is a common condition, and when not treated it can cause damage to the brain, heart, blood vessels, kidneys . Generic name: diltiazem [dil-TYE-a-zem] HCl Injection Based on this relationship, the mean plasma diltiazem concentration required to produce a 20% decrease in heart rate was determined to be 80 ng/mL. In a ten-subject randomized, open label, 4-way crossover study, coadministration of diltiazem (120 mg bid, diltiazem SR for 2 weeks) with a single 20 mg dose of lovastatin resulted in a 3- to 4-fold increase in mean lovastatin AUC and Cmax versus lovastatin alone. 0000000956 00000 n Dermatologic: Pruritus, sweating 332 33 As with all drugs, care should be exercised when treating patients with multiple medications (see PRECAUTIONS, General and Drug Interactions). High blood pressure adds to the workload of the heart and arteries. 0 These VPBs are transient, are typically considered to be benign, and appear to have no clinical significance. Mean plasma diltiazem concentrations of 130 ng/mL and 300 ng/mL were determined to produce reductions in heart rate of 30% and 40%. Although clear benefit has not been demonstrated with thermal applications, it remains a standard supportive care. Subsequent dose adjustments may be necessary during coadministration, and should be based on clinical assessment. Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter. hb```l Photographic documentation can be helpful for follow-up procedures. In terms of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapeutic drugs in the tissues surrounding the IV site. For the most part, blood does not backflow. Patients taking other drugs that are substrates of CYP450 3A4, especially patients with renal and/or hepatic impairment, may require dosage adjustment when starting or stopping concomitantly administered diltiazem in order to maintain optimum therapeutic blood levels. information highlighted below and resubmit the form. Sterile 10 mL Single-Dose Vial, Rx only NDC 55150-426-10 You should not breastfeed while using this medicine. Swallow right away without chewing. Gastrointestinal: Anorexia, diarrhea, dysgeusia, dyspepsia, mild elevations of SGPT and LDH, thirst, weight increase To make sure diltiazem is safe for you, tell your doctor if you have: if you also take digoxin, or a beta blocker (such as atenolol, carvedilol, metoprolol, propranolol, sotalol, and others). Before taking diltiazem, tell your doctor if you have kidney disease, liver disease, or congestive heart failure. Extravasation:Unintentional leakage of fluid out of a blood vessel into surrounding tissue. Supplement 2. The first method may be appropriate following extravasation of vesicant drugs and involves administration of an antidote (if available) and the application of cold compresses 3-4 . Inject subcutaneously or intradermally into the extravasation site using a 25-gauge needle or smaller. It works by affecting the movement of calcium into the cells of the heart and blood vessels. At the first sign of extravasation, nursing intervention with following steps is recommended: stop administration of IV fluids immediately, disconnect the IV tube from the cannula, aspirate any remaining drug from the cannula, administer drug-specific antidote, and notify the physician. Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use diltiazem only for the indication prescribed. 0000029456 00000 n With the practical use of these guidelines, it is expected to reduce the occurrence rate of extravasation and contribute to patient care improvement. Diltiazem exhibits frequency (use) dependent effects on AV nodal conduction such that it may selectively reduce the heart rate during tachycardias involving the AV node with little or no effect on normal AV nodal conduction at normal heart rates. Dermatologic: Alopecia, erythema multiforme (including Stevens-Johnson syndrome, toxic epidermal necrolysis), exfoliative dermatitis, leukocytoclastic vasculitis, petechiae, photosensitivity, purpura, rash, urticaria HHS Vulnerability Disclosure, Help - Small and fragile veins in infants, children, or elderly patients, - Cancer patients with hardened and thickened vessels due to frequent venipuncture, - Patients with vessels that move easily during venipuncture attempts, - Patients with excised lymph nodes, limb amputation, or closed vena cava, - Obesity in which peripheral venous access is more difficult, - Inadequate choice of equipment (peripheral catheter choice, size, or steel needle). HCl Injection The primary outcome was the change in SBP 60 min (+/- 30 min) after initial IV diltiazem administration. %PDF-1.4 % Vesicant extravasation:Leakage of a drug that causes pain, necrosis, or tissue sloughing. trailer - Check for blood backflow before/during administration, and always rinse the catheter with a saline solution in between administrations. Management of extravasation policy: version 01 [Internet]. Administration of oral doses ranging from five to ten times greater (on a mg/kg basis) than the daily recommended oral antianginal therapeutic dose has resulted in embryo and fetal lethality. After constant rate intravenous infusion to healthy male volunteers, diltiazem exhibits nonlinear pharmacokinetics over an infusion range of 4.8 to 13.2 mg/h for 24 hours. It is not known whether diltiazem will harm an unborn baby. Do not stop taking this medication without first talking to your doctor. Physical incompatibilities (precipitate formation or cloudiness) were observed when diltiazem hydrochloride injection was infused in the same intravenous line with the following drugs: acetazolamide, acyclovir, aminophylline, ampicillin, ampicillin sodium/sulbactam sodium, cefamandole, cefoperazone, diazepam, furosemide, hydrocortisone sodium succinate, insulin (regular: 100 units/mL), methylprednisolone sodium succinate, mezlocillin, nafcillin, phenytoin, rifampin, and sodium bicarbonate. IV: intravenous. Grapefruit and grapefruit juice may interact with diltiazem and lead to unwanted side effects. 3. . You may also need frequent blood tests. This product is available in the following dosage forms: There is a problem with Diltiazem 0000001363 00000 n 0000001694 00000 n 0000022294 00000 n The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Should a dermatologic reaction persist, the drug should be discontinued. Three solutions were used: 1/2 saline (154 mOsm), normal saline (308 mOsm), and 3% saline (1027 mOsm). Drugs which induce or inhibit hepatic microsomal enzymes may alter diltiazem disposition. Drug information provided by: Merative, Micromedex. The effect of cyclosporine on diltiazem plasma concentrations has not been evaluated. 0000017632 00000 n - Directions: apply hot fomentations for 20 to 30 minutes four to 6 times per day (for 1 day or more). 4 Hyaluronidase has been successfully used in the treatment of TPN extravasations. endstream endobj startxref Disconnect the IV tubing but DO NOT remove the catheter or needle. If these agents are to be administered concurrently, cyclosporine concentrations should be monitored, especially when diltiazem therapy is initiated, adjusted or discontinued. official website and that any information you provide is encrypted High blood pressure adds to the workload of the heart and arteries. Use within 24 hours. Although not observed in clinical trials with diltiazem hydrochloride injection, the following events associated with oral diltiazem may occur: The .gov means its official. Due to concern of potential extravasation and local tissue injury, central venous catheter (CVC) is the preferred route for vasopressor administration [].Despite this concern, vasopressors are administered via peripheral lines, often in resource . Received 2020 Jul 16; Accepted 2020 Jul 16. Digitalis - Intravenous diltiazem has been administered to patients receiving either intravenous or oral digitalis therapy. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Cleanse the extravasation site gently with an alcohol sponge, insert the needle of the TB syringe into the subcutaneous tissue around the site and gently aspirate as much of the solution as possible Avoid friction or pressure to the affected area 5. The National Extravasation Information Service website [Internet] [cited 2020 Jul 10]. HCl Injection The following adverse reaction rates are based on the use of diltiazem hydrochloride injection in over 400 domestic clinical trial patients with atrial fibrillation/flutter or PSVT under double-blind or open-label conditions. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. Barton-Burke M, Wilkes GM, Ingwersen KC, Bean CK, Berg D. Cancer chemotherapy: a nursing process approach. Tell your doctor about all medicines you use, and those you start or stop using. The therapeutic benefits of diltiazem in supraventricular tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness. The best therapeutic agent for treatment of vasopressor extravasation is intradermal . A defibrillator and emergency equipment should be readily available. Conceptualization: JTK, JYP, HJL, YJC. Other drugs that are specific substrates, inhibitors, or inducers of this enzyme system may have a significant impact on the efficacy and side effect profile of diltiazem. Tips Extended-release diltiazem capsules should be taken on an empty stomach (this means one hour before food or two hours after food). - Check if there is any local discomfort or swelling by running a saline solution through the catheter, and then inject the drug. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). (5 mg/mL) Take diltiazem exactly as prescribed by your doctor. Rhinitis, headache, and constipation are commonly reported side effects. Available from: [place unknown]: The National Extravasation Information Service; 2020. Liver cirrhosis was shown to reduce diltiazem's apparent oral clearance and prolong its half-life. No evidence of impaired fertility was observed in a study performed in male and female rats at oral dosages of up to 100 mg/kg/day. The therapeutic benefits of diltiazem in supraventricular tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness. Elevate the affected extremity startxref In domestic controlled trials, bolus administration of diltiazem hydrochloride injection was effective in converting PSVT to normal sinus rhythm in 88% of patients within 3 minutes of the first or second bolus dose. Apply compresses for 20 to 60 minutes 3 or 4 times daily for the first 24 to 72 hours after extravasation occurs. 1Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul, Korea, 2Department of Clinical Nursing, University of Ulsan, Seoul, Korea. Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection.
West Coast Curepen Strawberry Banana Strain, Where Do Emma And Ellie Live In Florida, Is Steve Mclendon Married, Tribal Jail Roster Pablo Mt, Articles D