CHHS18/148

Canberra Hospital and Health ServicesClinical Guideline Adrenaline (epinephrine) Intravenous Challenge (Adults)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Intravenous Adrenaline Challenge..........................................................................2

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

Definition of Terms...................................................................................................................5

References................................................................................................................................ 6

Search Terms............................................................................................................................ 6

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Guideline Statement

BackgroundAn 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 ObjectiveProvide 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.

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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).

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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

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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: o 12 lead ECGo Blood pressure o Heart rateo 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

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Time (minutes) STRENGTH0-5 0.025 mcg/kg/min5-10 0.05 mcg/kg/min10-15 0.1 mcg/kg/min15-20 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 60 640.05mcg 67.5 75 82.5 90 98 105 112.5 120 127.50.1mcg 135 150 165 180 195 210 225 240 2550.2mcg 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 82.5 860.05mcg 135 142.5 150 157.5 165 172.50.1mcg 270 285 300 315 330 3450.2mcg 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 infusionThe 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 complicationsDoc Number Version Issued Review Date Area Responsible PageCHHS18/148 1.0 25/05/2018 01/05/2021 Medicine 4 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Ventricular arrhythmias

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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.

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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

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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.

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References

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

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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.

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Search Terms

Long QT syndrome, Adrenaline challenge, QTcBack 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

MedicineCHHS Policy Committee

This document supersedes the following: Document Number Document Name

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