Time-Critical Infusions for Children (#1): Peripheral Adrenaline
Preparation
Information for facilitator
This teaching session is designed to be delivered on the ED shop floor to a small group (at least 1x Prescriber, 2x Nurses). It generally runs for 20 minutes.
Aim
The aim for this session is to give staff an understanding of why IV Adrenaline is used, how it is prescribed, and how to prepare it for use in the Emergency Department.
What you will need
There are several components to this session:
Part 1 (pages 2-3) contains background information and can be read by the facilitator to the group.
Part 2 (page 4) details a scenario involving the prescription and preparation of the drug. This can be done in the department, in real time, using real equipment. The drug, when found in the department, can be replaced for the purpose of practice, with a vial of water for injection or saline.
Part 3 (page 5-7) contains additional info including where guidelines, equipment and drugs can be found in the department, and also includes a simplified version of the local guideline and example prescription so that the prescription can be checked.
Introduction
“This short session is designed to introduce prescribers and nurses to the prescription, preparation and use of peripheral adrenaline in the Emergency Department. Peripheral adrenaline is infrequently used in ED, but when required needs quick preparation and administration in children presenting with shock not responding to boluses of fluid. We will run a brief scenario involving the prescription and preparation of peripheral adrenaline, then discuss how it works and why we give it.”
Indications and mechanism of action
Adrenaline is a hormone produced by the adrenal glands. It stimulates a widespread sympathetic response, including increasing cardiac output and causing vasoconstriction. In the case of refractory shock, it is used in order to increase blood pressure in order to provide better organ perfusion.
Adrenaline infusion is commonly used in an intensive care setting to support blood pressure but it is used via a central line. At a lower concentration, it can be used via peripheral IV access, i.e. a peripheral cannula, or intraosseous/IO line.
Peripheral adrenaline is indicated in children with circulatory shock which persists after 2 x 20 ml/kg fluid boluses. Input from local Paediatric and Paediatric Intensive Care teams is recommended at this stage.
Signs of circulatory shock include:
Prolonged central capillary refill
Hypotension
Tachycardia
Metabolic acidosis
Peripheral adrenaline may also be indicated in children with persistent shock who also develop signs of congestive heart failure with lower volumes of fluid and in which additional boluses are contraindicated.
Signs of congestive heart failure include:
Respiratory crackles on auscultation
Hepatomegaly
Starting peripheral adrenaline
Peripheral adrenaline is prepared at a lower concentration compared to when used centrally. An initial rate of 0.05 microgram per kg per minute is recommended. This can be titrated up to a maximum of 0.2 microgram/kg/min according to clinical response.
Monitoring peripheral adrenaline
Whilst on peripheral adrenaline, close monitoring is required.
Monitoring for peripheral adrenaline infusion includes:
Regular clinical review to assess response
Continuous cardiac and saturations monitoring
Regular blood pressure monitoring
Children on adrenaline in the ED will be monitored in an HDU or Resus (ER) bay and will require HDU or ITU-level care.
Scenario
Scenario script
“A 4-year-old boy has presented to ED with sepsis and shock which has not responded to two 20ml/kg boluses of saline. Please prepare for a peripheral adrenaline infusion.”
Instructions
Run this scenario in the Emergency Department, and expect participants to find their own equipment including guidelines and medications. Instead of using actual vials of adrenaline, once these are found, hand the nurse vials of water for injection or saline to serve as a substitute.
Step One
One team member will need to find instructions for preparation. Either use the paediatric intensive care drug infusion guide poster, or the IV monograph.
Prescriber to prepare prescription using poster or IV monograph, using an estimated weight of 16 kg.
Step Two
Nurse to prepare per the infusion guide or monograph.
Step Three
Nurse to set up infusion via pump.
Resources
Drug chart
Adrenaline 1:1000 dummy vials (filled with 1 ml 0.9% saline, labelled Adrenaline 1:1000 1mg/ml)
5ml and 50ml syringes
100ml bag of 0.9% sodium chloride
Drawing up needles
Syringe driver
Luer-lock extension/infusion line
How to prescribe adrenaline
Prescribe 75 micrograms per kg of adrenaline, in 50 ml of either 5% dextrose or 0.9% sodium chloride. This runs between 2 to 8 ml per hour to give a dose of 0.05 to 0.2 microgram per kg per minute.
Example for a 4-year-old (16 kg) patient:
How to prepare adrenaline
Draw up 75 micrograms per kg of adrenaline from a 1:1000 vial.
Make this up to 50 ml using 5% dextrose or 0.9% sodium chloride in a 50ml syringe.
Run via syringe driver between 2 to 8 ml per hour (0.05 to 0.2 micrograms per kg per minute).
Usual starting dose of 0.05 micrograms per kg per hour.
Additional Resources
- Peripheral Vasoactive Drugs in Kids (Paediatric Emergencies)
- Epinephrine for SHOCK (Paediatric EM Morsels)
- Septic Shock in Children (UpToDate)
- The Path to Great Paediatric Septic Shock Outcomes (Ames, et al.)
- LOCAL ONLY: IV Monographs (UHL Medusa)
- LOCAL ONLY: Children's Sepsis Guideline (UHL)
