ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
Antiarrhythmics Pregnancy: Avoid prolonged use — beta-blockers associated with foetal growth restriction; short-term perioperative use considered acceptable with monitoring

Esmolol

Brand names: Brevibloc

Adult dose

Dose: 500 mcg/kg IV loading over 1 minute, then 50–200 mcg/kg/minute infusion
Route: IV
Frequency: Bolus then continuous infusion; titrate every 4 minutes
Max: 200 mcg/kg/minute
For rate control: 500 mcg/kg bolus, then 50–200 mcg/kg/min. For hypertension: 80 mg bolus then 150 mcg/kg/min. Use dedicated IV line. Very short half-life (9 minutes) — safe for titration.

Paediatric dose

Dose: 100–500 mcg/kg loading mcg/kg
Route: IV
Frequency: Then 25–200 mcg/kg/minute infusion
Max: 1000 mcg/kg/minute
Seek specialist opinion; used in paediatric cardiac surgery for rate control and peri-operative hypertension

Dose adjustments

Renal

Metabolite (ASL-8123) accumulates in renal failure — use with caution in severe renal impairment; short half-life of parent drug unchanged

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Seek specialist opinion; used in paediatric cardiac surgery for rate control and peri-operative hypertension

Clinical pearls

  • Mechanism: cardioselective beta-1 receptor blocker — very short-acting due to rapid hydrolysis by red blood cell esterases; half-life of 9 minutes; provides predictable and titratable IV beta-blockade
  • Rapid onset and offset: uniquely titratable IV beta-blocker — can be started, adjusted, and stopped within minutes; ideal for haemodynamically unstable patients requiring rate control who may deteriorate
  • Key indications: rate control in acute AF/flutter (with good LV function); perioperative tachycardia and hypertension; SVT; thyroid storm (initial rate control); aortic dissection (IV beta-blocker to reduce rate and BP)
  • ESC AF guidelines 2020: esmolol IV as first-line rate control option for acute AF — rapid onset, titratable, short duration allows quick adjustment if haemodynamic compromise occurs
  • Aortic dissection: esmolol IV is preferred beta-blocker — target HR below 60, SBP 100–120 mmHg; superior to labetalol for fine HR titration in acute dissection
  • MHRA: licensed for rate control in SVT and perioperative tachyarrhythmias; off-label use in acute AF and aortic dissection well-supported by guidelines

Contraindications

  • Severe bradycardia (HR below 50 bpm)
  • Second or third degree AV block (without pacemaker)
  • Cardiogenic shock
  • Decompensated cardiac failure
  • Severe reactive airway disease (beta-blocker-induced bronchospasm)

Side effects

  • Hypotension (most common — dose-dependent; resolve by stopping infusion)
  • Bradycardia
  • Dizziness, somnolence
  • Local infusion site reactions (concentrated solution is irritant — use 10 mg/mL or dilute to 10 mg/mL)
  • Nausea and vomiting

Interactions

  • Digoxin (additive bradycardia — monitor HR and AV conduction; synergistic for rate control)
  • Calcium channel blockers (verapamil, diltiazem) — additive negative chronotropic/inotropic effects; AVOID IV combination
  • Alpha-agonists (additive hypertension in pheochromocytoma — block compensatory tachycardia)

Monitoring

  • Heart rate and rhythm (continuous ECG monitoring during infusion)
  • Blood pressure (hypotension monitoring — continuous BP monitoring recommended)
  • Respiratory status (bronchospasm risk in asthmatic patients)
  • IV site (concentrated solution — phlebitis risk; use large peripheral or central line)

Reference: BNFc; BNF 90; ESC AF Guidelines 2020; AHA Perioperative Beta-Blocker Guidelines; ESC Aortic Disease Guidelines 2014; MHRA SPC. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Pathways