wonky Adenocard prescription

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    This is going to be a question/rant. I had a patient the other day (I work in Tele) with a heart rate sustaining in the 130's-140's and the attending cardiologist was VERY rude to me after I questioned him regarding his prescription for PRN Adenocard.

    First of all, the order read "Adenocard, 6-12 mg, PRN systolic BP >150." That's it. No parameters, no frequency, nothing. I am a relatively new nurse, and was confused about the range "6-12." Did he mean 6 or 12 mg? Between 6 and 12 mg? If it was between, didn't that mean I would be technically prescribing the med? And how would I know when to give which amount?

    When I approached my charge nurse to see if she could advise, she gasped and said "Never, NEVER push this medication on this unit without the MD present at bedside. You could put the patient into cardiac arrest." I guess this is because Adenocard momentarily stops the heart before 'resetting' it. So then pharmacy calls and asks me about me order, and at that point I just figured it would be best to ask the MD, who was still on the floor at that point.

    I brought the copy of the order to him and asked him to clarify, and his response was "I don't see where the confusion is." I explained my question and he stated, VERY rudely, "Well, MOST nurses know what that means." I was livid! First of all, I am a new nurse (been on the floor about 5 months, 1 1/2 on my own), and second, his order was very unclear!

    What have been your experiences with Adenocard? Do you IVP it on your floors? Does the MD need to be present? Thanks for all replies
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  4. 0
    the order was for "adenocard, 6-12 mg, prn systolic bp >150" adenocard is for heart rate. whether or not it need an md at the bedside depends on your facilities policies and procedures. did you check with pharmacy? yes there will be a moment of asystole before the heart resets and restarts. adenosine needs to be given in a very specific manner to be effective.

    whether or not "most nurses know what that means" most md's can write a proper order. prn adenosine? that is a pretty aggressive med to be given prn.

    are you sure it wasn't apresoline which is for bp? but that wouldn't be 6-12 mgs. never give a med you aren't familiar with until you check with your charge nurse or supervisor. i'd even call icu to check.

    some md's are just jerks....don't let him fluster you. consider the source.

    intravenous adenocard (adenosine injection) is indicated for the following.

    conversion to sinus rhythm of paroxysmal supraventricular tachycardia (psvt), including that associated with accessory bypass tracts (wolff-parkinson-white syndrome). when clinically advisable, appropriate vagal maneuvers (e.g., valsalva maneuver), should be attempted prior to adenocard administration.

    it is important to be sure the adenocard solution actually reaches the systemic circulation (see dosage and administration).

    adenocard does not convert atrial flutter, atrial fibrillation, or ventricular tachycardia to normal sinus rhythm. in the presence of atrial flutter or atrial fibrillation, a transient modest slowing of ventricular response may occur immediately following adenocard administration.

    dosage and administration

    for rapid bolus intravenous use only.

    adenocard (adenosine injection) should be given as a rapid bolus by the peripheral intravenous route. to be certain the solution reaches the systemic circulation, it should be administered either directly into a vein or, if given into an iv line, it should be given as close to the patient as possible and followed by a rapid saline flush.

    adult patients the dose recommendation is based on clinical studies with peripheral venous bolus dosing. central venous (cvp or other) administration of adenocard has not been systematically studied.

    the recommended intravenous doses for adults are as follows:

    initial dose: 6 mg given as a rapid intravenous bolus (administered over a 1-2 second period).

    repeat administration: if the first dose does not result in elimination of the supraventricular tachycardia within 1-2 minutes, 12 mg should be given as a rapid intravenous bolus. this 12 mg dose may be repeated a second time if required

    adenocard i.v. (adenosine) drug information: indications, dosage and how supplied - prescribing information at rxlist
  5. 1
    oops...that was a mistype...long day/week. I meant heart rate >150!
    Esme12 likes this.
  6. 0
    First I would clarify who's correct between your team lead and the MD about if an MD must be present. On the tele floor where I work the MD is not required to be present, although they are required in the ER and on the med-tele floor. While the tele floor doesn't have to have an MD present, the are required to have pacing pads on the patient and have the pacing function ready to go at the push at the button. I've pushed it many times and never had to pace, although it is tempting. Even though it's not required on the tele floor, many MD's chose to be present if the first dose since pushing adenosine will only terminate an AV node dependent re-entry tachycardia. Otherwise it won't terminate it, but it will slow the ventricular response enough to reveal the underlying rhythm better, something the MD should be interested in seeing.

    In theory, if you do need to pace it won't be for long since adenosine has a half-life of less than 10 seconds. This is why when we do get prn adenosine orders on a patient it doesn't have a frequency, since by the time you draw up another dose the previous dose is inactive.

    Depending on your facility policy, a range order may or may not be acceptable, in general though following a range order is not prescribing, but there does need to be common understanding of how it will be interpreted between MD and Nurse, which in the case of adenosine usually means 6mg then double it to 12mg (or more if they've recently consumed caffeine).

    While a frequency isn't really needed in practical terms, there should be a limit to the number of doses, if you're giving it every 5 minutes with no effect at some point the MD needs to reevaluate. However there are patients where this type of order with repeated doses is appropriate and works fine.
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    I've given adenosine several times per ACLS protocol, which is my organizations ICU policy (note: had similar policy on a step-down unit). We always notify the doc, ideally they are at the bedside for our comfort, but if the pt is symptomatic, its not required. It is known per ACLS that the initial dose is 6mg. If that fails, 12mg. But the order is still unclear and likely dangerous. Like another user said, it's to be given a certain way (pushed fast, special stop cocks, blah blah). A couple things: if you're not on a unit that can freely give certain ACLS drugs, it prob shouldn't be ordered prn. Second, there must be a reason the doc ordered it prn, so why doesn't the doc transfer the pt to a place that can give it freely? Also, just saying HR>150 is vague. I've seen sinus tach > 150 and asymptomatic Vtach > 150. Both clearly would require interventions other than adenosine!!! If you ask me, the doc is an idiot and you did nothing wrong.


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