Adrenaline (epinephrine) Intravenous Challenge (Adults)

CHHS18/148

Canberra Hospital and Health Services

Clinical Guideline

Adrenaline (epinephrine) Intravenous Challenge (Adults)

Contents

Contents1

Guideline Statement2

Scope2

Section 1 – Intravenous Adrenaline Challenge2

Implementation5

Related Policies, Procedures, Guidelines and Legislation5

Definition of Terms5

References6

Search Terms6

Guideline Statement

Background

An intravenous adrenaline challenge aims to establish an electrocardiographic (ECG) diagnosis of long –QT syndrome through the administration of an adrenaline infusion in a controlled environment with continuous cardiac monitoring.

Key Objective

Provide Canberra Hospital and Health Services (CHHS) staff guidance for administration of intravenous adrenaline challenge.

Alerts

Patient must not have beta blockers 48 hours prior to testing

Patient must be admitted to the Coronary Care Unit (CCU) and connected to continuous cardiac monitoring before commencing the test

Ensure patient is aware that they are not to drive themselves home and has organised a responsible adult to transport them and be present with them for 24 hours post procedure.

Back to Table of Contents

Scope

This document applies to all patients who require testing for diagnosis of long QT syndrome at CHHS

This procedure applies to the following professionals working within their scope of practice:

· Cardiologist

· Cardiology advanced trainee (AT)

· Registered Nurse competent in Advanced Cardiac Life Support (ACLS).

Back to Table of Contents

Section 1 – Intravenous Adrenaline Challenge

Equipment

· Continuous Cardiac monitor

· ECG machine

· Resuscitation trolley and defibrillator

· Adrenaline infusion, see medication preparation below

· B-Braun Pump

· Intravenous giving set

Medication preparation

· Adrenaline 1mg/mL ampoule

· 5% glucose solution 500ml

· Intravenous giving set

Add adrenaline 1mg/mL ampoule (1000mcg) to 5 % glucose solution, this results in an adrenaline concentration of 2 mcg/mL. The adrenaline infusion should be labelled in accordance with the National Standard for User- applied Labelling of Injectable Medicines, Fluids and Lines.

Pre Procedure

· If the patient is not an inpatient at CHHS, admit the patient to CCU

· Obtain consent as per ACT Health and Consent and Treatment Policy and CHHS Patient Identification and Procedure Matching Policy

· This test can also be performed in conjunction with a Flecainide challenge test

· The patient needs to fast for a minimum of 6 hours before the test

· The patient must not have beta blockers 48 hours before the test

· Complete a 12 lead ECG on the patient

· Attend full set of observations on the patient as per Modified Early Warning Score (MEWS) chart prior to commencement of infusion

· Ensure the patient has a patent intravenous cannula insitu inserted as per Peripheral Intravenous Cannulation , Adults and Children (not neonates) procedure

· Defibrillator and resuscitation trolley should be located at the patient’s bedside and must remain so for the duration of the procedure

· Attach the patient to a continuous cardiac monitor.

Monitoring during procedure

· The patient requires continuous cardiac monitoring throughout the procedure

· A registered nurse and a Cardiologist and/or a Cardiac Advanced Trainee (AT) are required to be present for the duration the procedure

· The following vital signs are to be taken and recorded every five minutes for the duration of the procedure:

· 12 lead ECG

· Blood pressure

· Heart rate

· Respiratory rate.

Dosage and administration

Infusion of adrenaline is started 0.025mcg/kg/min

The dose is then doubled every 5 minutes for a maximum duration of 20 minutes, as per the following table

Time (minutes)

STRENGTH

0-5

0.025 mcg/kg/min

5-10

0.05 mcg/kg/min

10-15

0.1 mcg/kg/min

15-20

0.2 mcg/kg/min

See table below for mL/hr rates for various weights and dosages

Rate (mcg/kg/min)

45kg

50kg

55kg

60kg

65kg

70kg

75kg

80kg

85kg

0.025mcg

33.75

37.5

42

45

48.6

52.5

56

60

64

0.05mcg

67.5

75

82.5

90

98

105

112.5

120

127.5

0.1mcg

135

150

165

180

195

210

225

240

255

0.2mcg

270

300

330

360

390

420

450

480

510

Rate (mcg/kg/min)

90kg

95kg

100kg

105kg

110kg

115kg

0.025mcg

67.5

71

75

79

82.5

86

0.05mcg

135

142.5

150

157.5

165

172.5

0.1mcg

270

285

300

315

330

345

0.2mcg

540

570

600

630

660

690

Post Adrenaline Challenge Test care

· Continuous cardiac monitoring remains in place for a minimum for 1 hour following the completion of the test with vital sign observations conducted every 15 minutes.

· The Cardiologist or AT is to analyse the corrected QT interval (QTc) from the ECG’s taken to determine whether the test is positive (QTc >30millisecond during infusion of 0.1mcg/kg/min) or negative.

· If the vital sign observations are within normal range and the test result is negative the patient is able to be discharged within 3 hours of test completion.

· If the patient has also had a Flecainide Challenge Test, they require hourly ECGS until the patient is ready to be discharged after 6 hours after the test if stable.

Termination of infusion

The adrenaline infusion is to be discontinued immediately if:

· The Patient’s systolic blood pressure of greater than 200mmHg

· Non-sustained ventricular tachycardia (VT) occurs

· Polymorphic VT  (a ventricular rhythm at a rate greater than 100 beats per minute with a continuously varying QRS complex) occurs

· Greater than 10 premature ventricular contractions per minute are detected

· T-wave abnormalities are evident

· The patient does not tolerate the infusion

Potential complications

· Ventricular arrhythmias

Back to Table of Contents

Implementation

This guideline will be made available on the Policy register. Staff will be notified in team meetings and ward in-services. Information will be incorporated into existing education and training programs. Senior CCU ACLS accredited staff will train new and junior staff only after they have achieved ACLS competency.

Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

Policies and Procedures

· Consent and Treatment Policy

· Patient Identification and Procedure Matching Policy

· Medication Handling Policy

· Vital Signs and Early Warning Scores Procedure

· Healthcare Associated Infections Procedure

· Code Blue Response (Medical Emergency) – ACT Health Emergency Management Plans

· Peripheral Intravenous Cannulation Adults and Children (Not neonates)

Guidelines

· National Standard for User-Applied Labelling of Injectable Medicines, Fluids and Lines

Legislation

· Medicines, Poisons and Therapeutic Goods Regulation (ACT) 2008

· Human rights Act 2004

· Health Records (Privacy and Access) Act 1997

· Work Health and Safety Act2011

Back to Table of Contents

Definition of Terms

Flecainide Challenge Test – Flecainide is an antiarrhythmic medication used to treat tachyarrhythmias (abnormally fast rhythms of the heart), restore normal heart rhythm and maintain a regular heart rate.

Back to Table of Contents

References

1. Adrenaline Challenge Calvary Health Care Bruce Procedure Version 5 CCID371473

2. Shimizu W, Noda T, Takaki H, Kurita T, Nagaya N, Satomi K, Suyama K, Aihara N, Kamakura S, Sunagawa K, Echigo S, Nakamura K, Ohe T, Towbin JA, Napolitano C, Priori SG 2003, “epinephrine unmasks latent mutant carriers with LQT1 form of congenital Long-QT syndrome, Journal of American College of Cardiology. Vol.41 pp.633-642

3. Skinner 2011, Guidelines for the diagnosis and management of familiar long-QT syndrome, Cardiac Society of Australia and New Zealand Clinical Guidelines, accessed 25/05/2017 www.csanz.edu.au/Education/Guidelines/ClinicalPracticeFiles/tabid/148/ctl/OpenSearchResults/Default.aspx?xsq=adrenaline+challenge+test

4. Stiles 2006, Epinephrine stress test can unmask concealed long-QT syndrome, MedScape, accessed 31/05/2017, http://www.medscape.com/viewarticle/788363#vp_2

5. A.Buxton -UpToDate. Waltham, MA:UptoDate, 2014- http://www.uptodate.com/polymorphic-ventricular-tachycardia.

6. Mims Online, 2018 Flecainide acetate https://www.mimsonline.com.au/Search/AbbrPI.aspx?ModuleName=Product Info&searchKeyword=Flecainide+acetate&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=30360001_2 accessed on 22 May 2018.

Back to Table of Contents

Search Terms

Long QT syndrome, Adrenaline challenge, QTc

Back to Table of Contents

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

18 Apr 18

New Document

Girish Talulikar, ED Medicine

CHHS Policy Committee

This document supersedes the following:

Document Number

Document Name

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS18/148

1.0

25/05/2018

01/05/2021

Medicine

1 of 6

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register