Effectiveness of 3rd Adenosine

[Burritomedic1127]

Wondering if anyone has successfully converted a SVT with the 3rd Adenosine dose? Protocols here are 6 mg, 12 mg, 12 mg. Personally never seen it work, either breaks/shows underlying rhythm with 6mg or nothing at all with all 3 doses

 

[STXmedic]

Wondering if anyone has successfully converted a SVT with the 3rd Adenosine dose? Protocols here are 6 mg, 12 mg, 12 mg. Personally never seen it work, either breaks/shows underlying rhythm with 6mg or nothing at all with all 3 doses

Same here. The one time I've had adenosine not work on the 6mg, it didn't work on either of the 12mg doses either, and I had to move to cardizem.

 

[Burritomedic1127]

Same here. The one time I've had adenosine not work on the 6mg, it didn't work on either of the 12mg doses either, and I had to move to cardizem.

Exactly. There's talk here about removing the second 12mg dose. Seems like it could just be a waste of time

 

[gotbeerz001]

Our protocols do not even include the second 12mg dose.

 

[medicsb]

So far I've never had adenosine not work within 2 doses. I can only think of a few times where 6mg didn't work and the other times, one dose of 12mg worked.

 

[Jason]

My protocol doesn't have the 3rd dose either. It use to have a 3rd dose, but it got removed.
1st dose 6mg IVP, 2nd dose (if needed) at 12mg IVP.
I've seen the 1st and 2nd dose work and not work, but I don't remember ever seeing a 3rd dose work.

 

[Angel]

in the ER, a doc successfully converted SVT @220's with 18mg adenosine.
maybe escalating doses (not repeating) would be more effective?

the one time I used it, it converted with 6mg

 

[Summit]

It depends on your goal... diagnostic or therapeutic. Diagnostic it might be more useful to repeat 12 if you need to "see."
Either way, I am not super clear on the literature supporting the 3rd 12mg dose. I can tell l you that we never do that in the unit or a RRT. Either we stop at 12 and try something else or go past it. I've pushed 18 a few times, once 24.

 

[Burritomedic1127]

It depends on your goal... diagnostic or therapeutic. Diagnostic it might be more useful to repeat 12 if you need to "see."
Either way, I am not super clear on the literature supporting the 3rd 12mg dose. I can tell l you that we never do that in the unit or a RRT. Either we stop at 12 and try something else or go past it. I've pushed 18 a few times, once 24.

Are there significant changes in adverse effects at the 18-24mg range? I'm assuming it is still metabolized quick

 

[Carlos Danger]

I've often wondered why the dosing stops at 12mg

 

[Summit]

Typically we were increasing repeat bolus in situations where there was no response or minimal rate effects from the lower doses. If we are trying to see what the underlying rhythm is for SVT and/or attempting to terminate AVNRT and we saw no or minimal slowing at 12mg, it is highly unlikely to see a complication from 18mg that would not have been seen at 12mg if 12mg had delivered the desired effect in the first place. We are NOT bolusing 24mg following 12mg that resulted in 6s of asystole followed by the resumption of the SVT.

I don't know the answer to why 12->12 in ACLS. I would guess it is because ACLS is written for everyone and that the 12mg repeat is due to a high likelihood that you could get a better response from 12mg from providers who are likely administering adenosine for the first time in years (or ever) and are going to deliver a higher effective dose to the AV node in the second 12mg dose as they figure out a better bolus technique. If you push this stuff all the time, there is no reason to push the same dose again.

As far as complications, this study used up to 90mg of adenosine to ensure precise stent placement during endovascular AAA repairs. For illustrative purposes, complications were minimal and they type that would be manageable outside the OR too by a competent provider. Of course, their goals were different, achieving ventricular asystole was their goal, as opposed to a temporary AV block, thus the high doses.

 

[Christopher]

I've taken to starting with 12 mg in 20 mL of saline all as one bolus. I'd enjoy a move to 12 mg then 18 mg then cardioversion.

 

[Burritomedic1127]

I've taken to starting with 12 mg in 20 mL of saline all as one bolus. I'd enjoy a move to 12 mg then 18 mg then cardioversion.

That is a interesting technique. Has the conversion rate changed using this approach? I've always had a line running, rapid push of the Adenosine and then have my partner squeeze the liter bag for a continuous flush immediately after the med administration

 

[Christopher]

That is a interesting technique. Has the conversion rate changed using this approach? I've always had a line running, rapid push of the Adenosine and then have my partner squeeze the liter bag for a continuous flush immediately after the med administration

No issues that I've seen with suspected AVNRT/AVRT.

 

[blindsideflank]

I've pushed 18mg in patients who said "it takes 18". Otherwise it's a phone call to exceed 12. Ill often start at 12 then decide what to do from there

 

[medicsb]

Anecdotal, but this technique never failed me: attach IV to
fluid using tubing that has a distal and proximal port; raise pt arm above head, turn fluid wide open, push adenosine through proximal port followed by immediate 10ml flush through distal port and then let fluid keep running. (Obviously, pinch off tubing when pushing adenosine and flush.)

18g in AC preferred but had success w/ IV in the hand.

 

[cruiseforever]

I had it work yesterday. 6 mg nothing, 12 mg nothing not even a pause, 2nd dose of 12 mg the pt. converted.

 

[medicaltransient]

Splash some cold water from the drug fridge in their face without warning them!

 

[Posterior]

We do a 6,12,18 dosing. However I've never had to use the third.

 

[Burritomedic1127]

Thanks for all the replies. Seems as if it will work with either the 6mg or first 12, with random conversions with second 12 mg. Or the rhythm just won't convert with Adenosine.