Cardioselective beta-blocker (ultra-short-acting) Pregnancy: Not recommended in pregnancy (limited data; animal reproductive toxicity). Should not be used during breast-feeding.

Esmolol hydrochloride

Brand names: Brevibloc

Esmolol hydrochloride is the salt form of esmolol used in intravenous preparations, an ultra-short-acting cardioselective beta-blocker for rapid control of heart rate and blood pressure in tachyarrhythmias and acute perioperative settings.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Supraventricular tachyarrhythmia: loading infusion 500 micrograms/kg/min for 1 minute, then maintenance infusion 50 micrograms/kg/min for 4 minutes; titrate. Effective maintenance range 50–200 micrograms/kg/min.

Route: Intravenous infusion (powder must be reconstituted/diluted before use; never give undiluted)

Frequency: Continuous IV infusion, individually titrated

Max: Maintenance doses above 200 micrograms/kg/min have not been shown to give significantly increased benefit; safety of doses above 300 micrograms/kg/min has not been studied

Titration: if inadequate response within 5 min, repeat 500 micrograms/kg/min for 1 min and increase maintenance by steps (100, then 150, then 200 micrograms/kg/min, each over 4 min). As target heart rate/BP approached, omit loading infusion and reduce increment to 25 micrograms/kg/min or lower (down to 12.5–25). Perioperative tachycardia/hypertension: (a) intraoperative — bolus 80 mg over 15–30 s then 150 micrograms/kg/min infusion, titrate up to 300 micrograms/kg/min; (b) on awakening — 500 micrograms/kg/min for up to 4 min then 300 micrograms/kg/min; (c) postoperative — 500 micrograms/kg/min loading over 1 min before each titration step (50, 100, 150, 200, 250, 300 micrograms/kg/min over 4 min). Elderly: start lower. Infusions longer than 24 h not thoroughly evaluated. Paediatric posology in fetched SPC was truncated — do not use for under-18s; consult a children's formulary.

Dose adjustments

Renal

Caution in renal insufficiency — the acid metabolite is renally excreted; its elimination half-life may increase to about tenfold with elevated plasma levels.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance
Severe sinus bradycardia (less than 50 beats per minute)
Sick sinus syndrome; severe AV-nodal conductance disorders (without pacemaker); 2nd or 3rd degree AV block
Cardiogenic shock
Severe hypotension
Decompensated heart failure
Concomitant or recent intravenous verapamil (must not be given within 48 hours of discontinuing verapamil)
Non-treated phaeochromocytoma
Pulmonary hypertension
Acute asthmatic attack
Metabolic acidosis

Side effects

Hypotension (very common; dose-related, can be severe)
Bradycardia (including severe bradycardia; cardiac arrest reported)
Dizziness (in association with symptomatic hypotension)
Nausea / vomiting
Injection / infusion site reactions
Diaphoresis

Interactions

Verapamil — concomitant or recent IV verapamil contraindicated; do not administer esmolol within 48 hours of stopping verapamil
Caution with other drugs that decrease peripheral resistance, myocardial filling, myocardial contractility or electrical impulse propagation (§4.5 not present in fetched bundle)

Clinical monograph

How it works

It selectively blocks beta-1 adrenoceptors to slow the sinus node and AV nodal conduction, and is rapidly broken down by red-cell esterases, giving a short half-life and quickly reversible action.

Prescribing in practice

It can cause marked hypotension and bradycardia and is contraindicated in severe bradycardia, high-grade AV block, decompensated heart failure and cardiogenic shock.
Concentrated ampoules require careful dilution and accurate infusion-pump administration, and extravasation can cause local tissue reactions.
Use cautiously in bronchospastic airways disease and in diabetes where hypoglycaemic warning signs may be masked.

Monitoring

Use continuous ECG and blood-pressure monitoring with regular checks of the infusion site, titrating against heart rate and blood pressure.

Counselling the patient

This medicine is given as a carefully controlled infusion that works quickly and wears off quickly.
Tell the team about light-headedness or discomfort where the drip enters the vein.

Evidence & guidelines

Intravenous esmolol is an established agent for acute, titratable beta-blockade in arrhythmia and perioperative care.

Reference: ESC 2020 AF guidelines; AAGBI guidelines; MHRA SPC; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways