MARSHALLTOWN MEDICAL & SURGICAL CENTER Marshalltown, Iowa
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1 MARSHALLTOWN MEDICAL & SURGICAL CENTER Marshalltown, Iowa CARE OF PATIENT POLICY & PROCEDURES Policy Number: 4:52 Subject: Purpose: Policy: Dobutamine Cardiac Perfusion Scan To administer medication to evaluate the status of myocardiac perfusion. The RN, under physician supervision, will assess, administer medication, and monitor the patient undergoing cardiac testing. Additional Information: 1. There are many patients with known or suspected coronary artery disease who cannot exercise on a treadmill and require pharmacologic induced stress testing. 2. Dobutamine drip graph and THR percentage chart accompany this procedure to assist staff with calculations. 3. Dobutamine infusion should be stopped for the following reasons: a. severe or progressive angina b. significant arrhythmias c. severe hypertension SBP >220 DBP >120 d. hypotension B/P decreases >30 mm Hg e. clinically significant ECG changes f. Attainment of THR - 85% g. Maximum Dobutamine dose - 50 mcg/kg/min with consideration 4. Monitor patient for the following adverse reactions: a. feeling of anxiety, shakiness, dizziness b. palpitations c. angina d. arrhythmias e. headache, nausea, vomiting f. hypertension g. hypotension Equipment List: IV infusion pump IV tray Emergency drug box CPR cart Oxygen Suction Portable monitor Dobutamine from pharmacy Timer Dobutamine drip graph Dobutamine Stress Test worksheet Dobutamine Protocol for use of Esmolol, Atropine, and Lidocaine
2 Dobutamine Cardiac Perfusion Scan Page 2 Content: Procedure Steps RN is responsible 1. Patient will be weighed by the nurse or technologist on admission to x-ray. 2. The target heart rate will be calculated after patient's age has been confirmed. 3. Procedure discussed with patient/family by staff and written consent obtained. 4. All patients are to have an IV started saline loc Jelco #22 or greater with 250cc D5W 5. Patient should be connected to monitor to obtain pulse rate, and blood pressure for baseline assessment. 6. Obtain baseline EKG prior to the administration of Dobutamine and every two minutes during the infusion and at1, 3, and 5 minutes after Dobutamine is discontinued. 7. Have Esmolol, Atropine, and Lidocaine dosages calculated and ready for use 8. Dobutamine will be administered as outlined on the Dobutamine drip graph or as ordered by the physician. 9. Pulse rate, and blood pressure will be obtained and documented at the end of each two minute stage. 10. Continue Dobutamine infusion for one minute after the radio tracer is injected or as ordered by the physician. 11. Record O 2 sat, pulse rate, and blood pressure at 1, 3, 5 minute intervals after the Dobutamine is discontinued or until patient vital signs return to baseline. 12. The IV fluids will be discontinued and the heplock flushed and kept in place until patient vitals return to near baseline. Key Points 1. The pharmacy will mix the Dobutamine - 50 mg Dobutamine in 50 D5W or 1 mg/ml. 2. The THR is 85% of max. per IHC chart. *The physician may request a higher % THR. 4. A T-connector should be used to provide an additional port for the injection of a radio tracer. 5. Baseline assessment can be used for future reference. 6. The Nuclear Medicine Technologist will do the initial EKG and continue EKG s throughout the test. 7. Refer to the Dobutamine protocol for usage guidelines. 8. The nurse will calculate the amount of Dobutamine (ug/kg/min) according to the patient's weight using the Dobutamine drip graph. The radio tracer will be injected by a Licensed Nuclear Medicine Technologist at the physician s request. (usually at peak HR). The Dobutamine drip will be piggybacked to the main line IV. An infusion pump must be used in the administration of the Dobutamine. 12. The nurse will discontinue the heplock after patient s vitals return to baseline.
3 Dobutamine Cardiac Perfusion Scan, Page 3 Originated by: Care of Patient Effective date: May 1996 Authorized by: Nuc Med Dir 3/10 Authorized by: COO/CNO Date Revision date: 4/97, 7/98, 10/01, 6/04, 10/09, 3/10 Review date: Distribution: Diagnostic Imaging, Cardiac Services Documentation: Patient assessment is documented on the Dobutamine Stress Test Worksheet. EKG's are recorded by the Nuclear Medicine Technologist Original EKG will be kept on file in the Cardiac Services; images and associated paperwork archived in PACS. Charges will be made by the Diagnostic Imaging department. Reference: Iowa Heart Center Protocol, Iowa Heart Center, Des Moines IA PDR MMSC Pharmacy MGMS Stress Testing Protocol, MCMS, Ames IA
4 Dobutamine Cardiac Perfusion Scan Page 4 DOBUTAMINE DRIP GRAPH I.V. Pump settings in ml/hr Wt. (kg) (0 min) 5 mcg (3 min) 10 mcg (6 min) 20 mcg (9 min) 30 mcg (12 min) 40 mcg
5 Dobutamine Cardiac Perfusion Scan Page 5 STRESS TESTS - PERCENTAGES Age 27 75% = % = % = % = % = % = 193 Age 28 75% = % = % = % = % = % = 192 Age 29 75% = % = % = % = % = % = 191 Age 30 75% = % = % = % = % = % = 190 Age 31 75% = % = % = % = % = % = 189 Age 32 75% = % = % = % = % = % = 188 Age 33 75% = % = % = % = % = % = 187 Age 34 75% = % = % = % = % = % = 186 Age 35 75% = % = % = % = % = % = 185 Age 36 75% = % = % = % = % = % = 184 Age 37 75% = % = % = % = % = % = 183 Age 38 75% = % = % = % = % = % = 182 Age 39 75% = % = % = % = % = % =181 Age 40 75% = % =144 85% =153 90% =162 95% = % =180 Age 41 75% = % =143 85% =152 90% =161 95% = % =179 Age 42 75% = % =142 85% =151 90% =160 95% = % =178 Age 43 75% = % =141 85% =50 90% =159 95% = % =177 Age 44 75% = % =140 85% =149 90% =158 95% = % =176 Age 45 75% = % = % = % = % = % = 175 Age 46 75% = % = % = % = % = % = 174 Age 47 75% = % = % = % = % = % = 173 Age 48 75% = % = % = % = % = % = 172 Age 49 75% = % = % = % = % = % = 171 Age 50 75% = % = % = % = % = % = 170 Age 51 75% = % = % = % = % = % = 169 Age 52 75% = % = % = % = % = % = 168 Age 53 75% = % = % = % = % = % = 167 Age 54 75% = % = % = % = % = % = 166 Age 55 75% = % = % = % = % = % = 165 Age 56 75% = % = % = % = % = % = 164 Age 57 75% = % = % = % = % = % = 163 Age 58 75% = % = % = % = % = % = 162 Age 59 75% = % = % = % = % = % = 161 Age 60 75% = % = % = % = % = % = 160 Age 61 75% = % = % = % = % = % = 159 Age 62 75% = % = % = % = % = % = 158 CONTINUED
6 Dobutamine Cardiac Perfusion Scan Page 6 STRESS TESTS - PERCENTAGES - continued Age 63 75% = % = % = % = %= % = 157 Age 64 75% = % = % = % = % = % = 156 Age 65 75% = % = % = % = % = % = 155 Age 66 75% = % = % = % = % = % = 154 Age 67 75% = % = % = % = % = % = 153 Age 68 75% = % = % = % = % = % = 152 Age 69 75% = % = % = % = % = % = 151 Age 70 75% = % = % = % = % = % = 150 Age 71 75% = % = % = % = % = % = 149 Age 72 75% = % = % = % = % = % = 148 Age 73 75% = % = % = % = % = % = 147 Age 74 75% = % = % = % = % = % = 146 Age 75 75% = % = % = % = % = % = 145 Age 76 75% = % = % = % = % = % = 144 Age 77 75% = % = % = % = % = % = 143 Age 78 75% = % = % = % = % = % = 142 Age 79 75% = % = % = % = % = % = 141 Age 80 75% = % = % = % = % = % = 140 Age 81 75% = % = % = % = % = % = 139 Age 82 75% = % = % = % = % = % = 138 Age 83 75% = % = % = % = % = % = 137 Age 84 75% = % = % = % = % = % = 136 Age 85 75% = % = % = % = % = % = 135 Age 86 75% = % = % = % = % = % = 134 Formula used to figure percentages: age = 100% 100% x % = % Example: = 193 (100%) 193 x 75% = or 145 is 75% 100% RATES AGE SED TRAIN % RATES SED TRAIN
7 Dobutamine Cardiac Perfusion Scan Page 7 DOBUTAMINE PROTOCOL Emergency Medications 1. WHEN DO YOU GIVE ATROPINE? A. Beginning 30mcg/kg/min level with no noticable increase in heart rate B. Heart rate is gradually decreased instead of increased C. Atropine 0.2mg-0.5mg IVP - observe monitor closely. May repeat dose of.2 mg to maximum dose of 2.0 mg per physician s order. 2. USES OF ESMOLOL: A. Heart rate has not started decreasing 3 minutes after Dobutamine was turned off. B. Images/echo have been obtained and patient is very uncomfortable with high heart rate. C. Patient begins having chest pain at higher doses with EKG changes. D. Esmolol 20 mg (2 cc or mg mg/kg) - may repeat dose X 1 five to ten minutes later, if patient has persistent symptoms or heart rate remains elevated 3. USES FOR LIDOCAINE PVC's are common with many of our patients. Treatment of their arrhythmias is usually unnecessary. Many times the arrhythmias are fleeting. Treatment with Lidocaine may be necessary if the patient is symptomatic with the arrhythmias. Treatment may also be beneficial for the PEAK images. Because of the computer triggering from the EKG's QRS complex, many PVC's will interfere. Lidocaine 50mg may be used to suppress the PVC's. P:\CAREPT\cpt4.52r2crk.doc
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