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??

[Anna Flaxis, BSN, RN]

Check your protocols. In my facility, even though we are all ACLS certified, we still need a physician order to administer adenosine. It doesn't state the physician has to be in the room, but I would prefer it, and I can't imagine any physician I work with opting not to be. We are not EMS- there is no reason we should have to function as if we are when we have doctors right there.

[sreynolds]

Thank you all so much. I think it was hard for me to deal with this situation because I was trained in my orientation to never push without a physician. But it makes sense that it's ok for a nurse to push it without a MD present since its part of the ACLS algorithm. This particular doctor is just very laid back can be abrasive so his response rubbed me the wrong way.

[FlyingScot, RN]

Thank you all so much. I think it was hard for me to deal with this situation because I was trained in my orientation to never push without a physician. But it makes sense that it's ok for a nurse to push it without a MD present since its part of the ACLS algorithm. This particular doctor is just very laid back can be abrasive so his response rubbed me the wrong way.

You need to check if your facility considers ACLS a protocol. Not all hospitals do.

[JustaGypsy]

I have also never given Metoprolol (Lopressor) 10 mg IVP in one go. Wow.

[applesxoranges, BSN, RN]

I would look at the med protocol or ACLS protocol. I would have pushed it but we would have had a crash cart. We normally have a running IV line (maybe a BP cuff hooked up to it to act as a pressure bag but not always) though and have two nurses. One with a normal saline at the top and one at the bottom with the adenosine. When adenosine nurse says done the other pushes.

Although last time my partner nurse didn't hold her syringe down so my flush started filling her syringe.

[Pheebz777, BSN, RN]

We normally have a running IV line (maybe a BP cuff hooked up to it to act as a pressure bag but not always) though and have two nurses. One with a normal saline at the top and one at the bottom with the adenosine. When adenosine nurse says done the other pushes.

Although last time my partner nurse didn't hold her syringe down so my flush started filling her syringe.

That's why I don't know why some nurses still use the "running IV line and use the next port up" method. Once you flush the adenosine, there will be some "running upward" of the medication from the force of pushing the adenosine. There is a large area of "dead space" filled with saline if you flush from the "next port up". Just a reminder, you have to SLAM the adenosine in there! No waste of precious seconds. I've seen nurses even use 1 luer lock port and screw off the adenosine, then screw on the flush.

Using a stop cock lets you flush the saline within micro seconds after pushing the adenosine on the lower port. You just have to hold down the adenosine syringe forcefully enough that the saline flush doesn't overpower your adenosine syringe hand. And you don't need 2 nurses to coordinate the flushing. Just your 2 hands, and your own internal timing.

I would recommend using your dominant hand to flush the ADenosine for more strength.

[2BS Nurse, BSN]

Has anyone pushed adenosine in an outpatient clinic setting?

[amzyRN]

I've always had pads on with an IV in the AC prior to pushing adenosine and always with an MD present at least nearby. The MDs I've worked with were always very cautious with SVT and other things like that. It is after all the MD that gets sued if things go bad. You should remind him privately of that fact. And he shouldn't have embarrassed you in front of a patient, totally unprofessional. You should talk to him privately because he shouldn't do that again to you. I'm very new too, less than 2 years experience.

[Guest374845]

That's why I don't know why some nurses still use the "running IV line and use the next port up" method. Once you flush the adenosine, there will be some "running upward" of the medication from the force of pushing the adenosine. There is a large area of "dead space" filled with saline if you flush from the "next port up". Just a reminder, you have to SLAM the adenosine in there! No waste of precious seconds. I've seen nurses even use 1 luer lock port and screw off the adenosine, then screw on the flush.

Using a stop cock lets you flush the saline within micro seconds after pushing the adenosine on the lower port. You just have to hold down the adenosine syringe forcefully enough that the saline flush doesn't overpower your adenosine syringe hand. And you don't need 2 nurses to coordinate the flushing. Just your 2 hands, and your own internal timing.

I would recommend using your dominant hand to flush the ADenosine for more strength.

Ultimately, all of the fuss over flushing contraptions for adenosine is unnecessary. All you need is your dose drawn up in 20-30cc of NS in a big syringe and giving it as a big bolus through a proximal IV. No, stopcock, no pressure bag, no second person doing a timed flush.

[Kuriin, BSN, RN]

Every single time I've used adenosine, I drop an 18g or larger in the most proximal vein that I can find and use a pressure bag to the max mmHg. Never had any problems and you don't have to fumble around with a stopcock.

[NuGuyNurse2b]

Ultimately, all of the fuss over flushing contraptions for adenosine is unnecessary. All you need is your dose drawn up in 20-30cc of NS in a big syringe and giving it as a big bolus through a proximal IV. No, stopcock, no pressure bag, no second person doing a timed flush.

Would that dilute the Adenosine?