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??

[calivianya, BSN, RN]

Technically speaking, ACLS protocol is PROTOCOL according to my hospital. As in, it's the same as any other standing protocol in the hospital, previously signed off by a MD as something ACLS nurses can do. We do not have to have a MD present and we don't have to have an MD tell us to give adenosine. It is a professional courtesy to tell the physician that is what we're about to do, but if the patient's HR is 170 and their BP is 50/20, we don't have to wait for them and we don't need a separate order. We are covered under ACLS (although, we should probably be cardioverting them in that situation instead).

We definitely hook the patient up to the crash cart first!

Our manager actually got on us about this at the last staff meeting. She said people had been waiting for the physicians to show up and that was a big no-no, and re-asserted we have the protocol and the training to push stuff ourselves.

[Anna Flaxis, BSN, RN]

...does Adenosine ever cause an arrest?

Rarely, but it has happened. Clinically significant brady and tachyarrhythmias, as well as VF have occurred after administration of adenosine, but these are rare. In general, adenosine has a pretty high safety profile and a good track record. However, if your patient were one of the extremely rare cases that went into VF after adenosine, wouldn't it be nice if you already had the pads on and could deliver a shock immediately?

Or, the more likely scenario, what if you gave the adenosine and it didn't work and the patient suddenly became unstable? You could perform synchronized cardioversion immediately, without delay, as you'd already have the pads on.

To the OP, I've given lots of adenosine, never without a doctor in the room. I've never been asked to. The doctor has always been in the room because they wanted to see whether the patient's rhythm would convert or slow down enough to see the underlying rhythm so they could make clinical decisions from there. While it's true that giving adenosine falls under ACLS protocols, I don't think it should be necessary for anyone to have to give it without physician oversight in a hospital setting- this is not prehospital medicine. I find this doctor's cavalier attitude and his condescending behavior toward you to be disturbing. I'm sorry you have to work with someone like that.

[LakeEmerald]

Aren't you supposed to push 6mg, then 12mg? Wonder why the MD told you to push another 6mg instead of 12mg? Not how it's usually done. In my ED, yes, the MD would be at bedside and heck yes, the pt would be on the defibrillator/cardioverter/monitor just in case. It's a big darn deal stopping and restarting someones' heart. Yes, it's usually fine, but, if the pt stayed in asystole or went into a lethal arrythmia, it would be YOUR **s.

Then you would be scrambling like a crazy person trying to get help, and everybody would wonder why you pushed it without the MD at bedside. You did right (except the 2nd dose, the MD ordered the wrong dose).

[Anna Flaxis, BSN, RN]

There isn't consensus on adenosine dosage. AHA ACLS protocol recommends 6mg then 12mg, and you can repeat the 12mg if needed. Others state to just start with 12mg, while others state 18mg. Typically, your facility protocol will probably be in line with ACLS.

Raising the arm is an unproven practice, but a lot of people still do it. I don't bother.

It would have been better to place a PIV closer to the heart, but unless there was an indication for an EJ, I'd have gone with an 18g. in the antecubital fossa.

I personally do not like the stopcock method- futzing around with the stopcock is too time consuming. I find it much quicker to have the syringe with adenosine attached to the port on a running IV line closest to the patient, with your flush attached to the next port up.

Adenosine does not actually stop the heart, per se. The pause you see is a sinus pause, not asystole.

I, too, am mystified by this physician's behavior.

[BecomingNursey]

I would've went ahead and administered it. I'm ACLS certified and in my hospitals policy that is enough to push it independently of a provider.

However, I also would've already had the patient on the monitor, hooked to the EKG machine (to catch the sinus pause rhythm strip), the defibrillator pads on (JIC), at least a 20 gauge IV (preferably in the left AC), a normal saline bag of fluids hung and ready to be utilized for flushing rapidly, and 18MG of adenosine @ bedside JIC the first 6MG didn't work and we ended up giving the maximum dose before cardio version.

I've personally administered adenosine at least 6-8 times in my short 1 year & 4 months of nursing and every time the patient has converted except for the last time and that time we got to cardiovert (which I personally thought was pretty cool. Not for the patient though).

That doctor sounds like they need to get their head out of their @$$ and focus more on their patient than what they think they need to do at their desk. I'm pretty sure SVT is a medical emergency serious enough for a physicians full attention. But what do I know? I'm "just a nurse." 😂😂😂

[hawaiicarl, BSN, RN]

Monitor on continuous record, adenosine attached to luer lock closest to pt, NS flush attached to the next port up. Push drug/flush/tear strip off monitor, then toss it in the Dr.'s face. Shouldn't take more than 10-15 seconds to make your point clear I also sort of use an adenosine order as a litmus test on orientees, if they unquestioningly march into the room to give it I get very nervous .... if they stop and ask questions, like you did then chances are they won't kill anyone follow blindly what the Dr. tells them, indicating they have potential.

Cheers

[wyosamRN]

I think whats really different about this is the lead up- if the patient presented with a rate in the 170's, most of the things you asked if the physician wanted prior to administration would normally be there by the time the doc sees them. Patient presents with rate in the 170s, they get a big line (2 if unstable/or if my gut says that's coming), they get pads, monitor and they get an EKG. Somewhere in that process, the doc comes in. Adenosine is already pulled and ready, RT is still there from initial EKG and records while we attempt to convert if that is what the doc wants to do. If the MD is busy, they get a quick report, and most likely say go for it on protocol. If unstable and MD not there, straight to protocols and work it by the book until they show up.

Dont be afraid to work from protocols/standing orders. Dont do it blindly- make sure what you are doing makes sense (no different that any other order), but they are there for a reason.

[canoehead, BSN, RN]

I would've told him he needs to be in the room when the patient is that unstable. And I would have documented "physician was requested to respond to pts bedside." I suppose I wouldn't delay treatment if I had the order and he was being an ass, but there would be a discussion afterwards, with him and my NM as well.

[ParalyticAgent]

...but if the patient's HR is 170 and their BP is 50/20, we don't have to wait for them and we don't need a separate order. We are covered under ACLS (although, we should probably be cardioverting them in that situation instead).

In that scenario, I would hope you would opt for cardioversion, since the patient is hemodynamically unstable.

[sonia88]

All really useful information, thanks.

[Guest838984]

I've given adenosine without the MD present but I had another nurse in the room with me. And yea that guy was extremely rude to you and shouldn't have treated you that way at all. I hate rude docs, they don't realize if there's a strain on the nurse-doc relationship that it just makes everything worse for the patients.

[littlepeopleRNICU]

I think you absolutely did the right thing, and the MD was unprofessional in attitude and practice. He should've stayed. No, in an ER, with a doc right there, I would never give it without the doctor present or pads and a monitor.