Adenosine administration

[sreynolds]

So I have a question...have any of you ever, or WOULD you ever, push adenosine without an MD present?

I was told to get 6mg of Adenosine to administer for HR around 170s. Sure. I can do that. The pt had a 20g in the hand...and I asked if he would like me to get another access in an EJ first. No, that isn't necessary, he says. Hand is fine. Do you want me to put the pads on first? Nah, that isn't necessary either, and he leaves the patients room. Dumbfounded, i go and grab the crash cart so I can hook some pads up anyways, and I grab the nurse I'm sharing a pod with to assist. We get the patient laid flat, arm up in the air, Adenosine positioned on one stop cock, a huge 30ml syringe full of NS hooked up the other side, and we were ready to go. We wait, and I said maybe the doctor doesn't realize we are ready. I run to get the doctor and he says, you haven't given it yet!!?? To which I respond, I don't feel comfortable pushing adenosine without you present. He rolled his eyes, huffed and says I don't know why you haven't given it, I guess you need me to come hold your hand?? I respond by telling him he can find a different nurse if he wants it given without him present, especially considering he did not want me to put pads on her just to be safe.

He comes to the room, we push the meds. Obviously it doesn't work. Why would it. He asks for 6mg more, I quickly drew it up, drew up more NS for a flush, we gave that as well....heart rate didn't so much as budge and patient didn't even notice. So he says ok, go get 10mg of metoprolol. Can you give that? Or do I need to watch you give that too? And good thing you put those pads on her that I told you were not necessary....And he walks out.

Thoughts? I'm a relatively new ER nurse, but not a new nurse. I've never been asked to give adenosine without a doctors presence. He made me feel incompetent, and that aggravates me because I feel I handled the situation correctly. Am I wrong??

[jamisaurus]

Honestly, in my opinion the MD treated you poorly. He was unprofessional and rude. It was something you weren't comfortable with, and he was disrespectful.

However, this means he's used to other nurses pushing it without him there. I would have pushed it and I have without a physician present with order of course (I do have ACLS). He was right around the corner if the patient didn't tolerate it, and so was your physician.

In my facility ACLS nurses can push it. I would investigate your policy, it might clear some things up for both you AND him.

[turnforthenurse, MSN, NP]

Wow what nerve! I agree, the MD treated you poorly and was unprofessional.

I have pushed adenosine many times in my career but it was always with a doctor present. They always wanted to stay in the room to see if the patient would convert or not.

[Lev, MSN, RN, NP]

You don't need a doctor present to push adenosine but I would have at least one other nurse in the room with you. I would use an AC line or higher since the half life of adenosine is less than 3 seconds which means it will not work most likely if you push it in the hand. Even if you give it with a large flush. You were right to put the pacer pads on the patient. What a prick!

[AZQuik]

Prick, but...

In our Ed a resident would likely stick around, but we can push it without notifying them until afterwards. I understand why he was huffy, but not how he was huffy. IMO, he wasn't wrong, just unprofessional and condescending. Which of course makes him wrong.

That should make perfect sense

Basically....he was unprofessional and rude about his opinion and his teammate.

BSN GCU 2014.

Sent from my iPhone using allnurses

[NurseOnAMotorcycle, ASN, RN]

Holy crap, I would have done everything you did except make sure there was at least a peripheral line in the AC since it's got such a short half life.

You did the right thing! What if it worked, but too well and no rhythm came back at all?

[Guest219794]

In answer to your 2 questions, yes and yes.

Regarding the doc- He is an ignorant schmuck.

As far as the comment regarding pads- I know everybody holds their breath during the pause. It a scary little time period. But does it ever not come back? In other words, does Adenosine ever cause an arrest?

[caroladybelle, BSN, RN]

Does adenosine ever cause arrest? Yes.

[AZQuik]

NoM is right. AC is much better than a hand. I learned from an old medic before I went to nursing school, ditch the infusion cap and hook a bag of saline up primed but not running. Inject adenosine into line with a small air bubble in front (most ports cause this bubble anyway) slowly open saline so the bubble is just shy of entering pt. stop the saline. When ready, have someone open the tubing up with someone else squeezing the bag of saline. This is the fastest way to get it to the heart through an AC line.

Done this about 25 times and always got a sinus pause. That said, they don't always convert.

Caveats: burp saline bag always in Ed. Just make it a habit.

I learned to do this in rigs so have always done it this way. 1 person admin can be done with a pressure bag (but there should always be more than one person if possible. CPR may follow)

Always have the code cart and pads hooked up. I usually hook me up to the defibrillator monitor as well, cardioversion will follow if they don't convert after a couple admins.

Always warn the pt "this is going to make you feel funny, and take your breath away" pts should always be lying down in a stretcher.

Never tell a pt this is going to stop your heart. It's a sinus pause, it will SLOW their heart considerably, but it will slow it down. 174 hr to 20 is going to feel like it stops. No need to make them nervous.

BSN GCU 2014.

Sent from my iPhone using allnurses

[CraigB-RN, MSN, RN]

Do it without doc present. It depends. It depends on state scope of practice and your hospital policies. In my old job, I did it all the time. In this job. Nope. Not a chance.

Don't need the pads but pt should be on continuous monitoring so you could catch underlying rythem if rate did slow down.

[Pheebz777, BSN, RN]

ER MD's can be your best friend or they can be the most overexaggerated drama queens you've encountered since Aunt Sally. LOL! Looks like you encountered one of them!

Don't let them get under your skin though, that's the important thing. In the ER, MD's expect you to perform on your own however it is up to you to voice out how uncomfortable you are in performing certain tasks. Talk to your charge RN for assistance if you find it difficult to voice out with your ER MD.

For instance, you could have just inserted another IV without asking the MD. You know you need to hook up the pads and EKG leads without asking the MD. You don't need the ER MD there at bedside unless the patient codes. Another nurse though is always my practice.

Oh, I forgot to ask, was this in an E.R. setting?

Anyway, don't forget to have at least 2 large bore IV's, hook up the defib pads as well as the EKG leads just in case you need to cardiovert (synchronized), have a stopcock attached (adenosine on the lower port, saline flush on the higher port), and don't forget to start printing the strip just prior to infusing the adenosine, and if possible request RT at bedside.

I've administered adenosine maybe over 20 times both in E.R. ICU, Cv-ICU and 1 time on the Telefloor. It's only been 50% effective in my experience. The other 50% were successful thru cardioversion combined with medication management (amiodarone, cardizem drips, etc), and so far no codes.

[AJJKRN]

Most here are probably aware but if not, I think it's worth mentioning that adenosine will not stop or pause someone in afib but may only slow the HR down long enough to see the Pt's in afib and not sinus tach.

Adenosine Monograph for Professionals - Drugs.com

Do not confuse Adenosine (Adenocard, Adenoscan) with adenosine phosphate (used as adjunctive therapy in the treatment of complications of varicose veins; see Adenosine Phosphate 92:92.). No evidence to suggest that the drugs are therapeutic alternatives.

Treatment of Supraventricular Tachyarrhythmias

Termination of paroxysmal supraventricular tachycardia (PSVT), including that associated with accessory bypass tracts (e.g., Wolff-Parkinson-White syndrome).1 14 24 26 31

Drug of choice for terminating stable, regular narrow-QRS-complex (narrow-complex) tachycardias, including supraventricular tachycardias (SVTs).7 26 31

Attempt appropriate vagal maneuvers (e.g., Valsalva maneuver, carotid sinus massage) when clinically indicated prior to adenosine use.1 24 31

Also has been recommended for treatment of stable, wide-complex tachycardias of supraventricular origin+ 28 31 or those with a previously defined reentry pathway†.31

May consider adenosine in patients with unstable narrow-complex reentry SVT while preparing for cardioversion†; however, do not delay cardioversion to administer the drug or to establish IV access.31 (See Cardiovascular and Cerebrovascular Effects under Cautions.)

Not effective in terminating arrhythmias not due to reentry involving the AV or sinus node (e.g., atrial flutter, atrial fibrillation, ventricular tachycardia).1 4 14 24 31 Risk of serious arrhythmias and/or hypotension in patients with preexcited arrhythmias.18 19 26 27 29 (See Cardiovascular and Cerebrovascular Effects under Cautions.)