5-Minute Pharmacy Pearl: Single Syringe of Diluted Adenosine for Termination of SVT

• Dosing
  • Supraventricular tachycardia
    • adenosine 6 milligrams (mg) may be given over 1 to 2 seconds followed by a 20 milliliter (mL) rapid saline flush. If there is no response in 1 to 2 minutes, a 12 mg IV bolus dose may be repeated twice followed by saline flushes 

• Mechanism of Action
  • Slows impulse formation in the sinoatrial (SA) node, slows conduction time through the atrioventricular (AV) node, and can interrupt reentry pathways through the AV node.

• Pharmacokinetics
  • Onset:  20 to 30 seconds
  • Duration: less than 10 seconds 
  • Metabolism: Adenosine is rapidly taken up by most types of cells, including cellular elements of the blood (erythrocytes) and vascular endothelium, where it is rapidly degraded by deamination to inosine and subsequently to hypoxanthine
  • Elimination: Total plasma clearance occurs in less than 30 seconds following intravenous administration

Administration Technique

1. How to mix single syringe diluted adenosine?
   • Grab a 20-30 ml syringe.
   • Draw up the adenosine AND the normal saline in the same 20-mL syringe.
   • Administer via fast IV push (can be through a running IV line).

Title: McDowell M, Mokszycki R, Greenberg A, et al. Single Syringe Administration of Diluted Adenosine. Acad Emerg Med. 2019 Oct 30. [ePub ahead of print]. [PMID 31665806]

• Methods
  • Single center, prospective, observational study was conducted from November, 1, 2016 through February 28, 2018 conducted at Advocate Christ Medical Center in Oak Lawn, IL
  • The physician would identify patients with SVT and would inform the pharmacist of their preferred adenosine administration method. The selection of the administration method was solely up to the provider regardless of admission into the study.
  • There were 26 patients in the single-syringe group and 27 patients in the traditional method group.

• Results
  • Successful conversion to NSR with the first
    dose was higher in the SS arm 73.1% (95% CI, 0.55 – 0.91) to 40.7% (95% CI, 0.21 – 0.61) (non-inferiority, p=0.0176).
    • Successful conversion to NSR with up to 3 doses was also higher in the SS arm 100% (95% CI, 1.0 – 1.0) to 70.4% (95% CI, 0.52 – 0.89) (non-inferiority, p=0.0043).
    • One patient in the conventional TS arm suffered extravasation and phlebitis compared to none in the SS arm.
• Conclusions
  • The SS administration method is simple and no less effective than the TS method.
  • Further randomized control studies should be completed to validate these results.

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• Comments from the author

• “One thing I wish we had prospectively evaluated was how satisfied the RNs were with the novel method.”
• Another thing that I wish we could have worked in was the number of patients who presented multiple times during the study period
• When patients showed up for their 3rd or 4th SVT they would ask us for the SS method

• Other FOAM Posts
  • https://www.aliem.com/2019/10/trick-of-trade-combine-adenosine-single-syringe/

• References
  • Page RL, Joglar JA, Calwell MA, et al. 2015 ACC/AHA/HRS guidelines for the management of adult patients with supraventricular tachycardia: Executive summary. Heart Rhythm 2016;13(4):e92-e135
  • Ketkar VA, Kolling WM, Nardviriyakul N, et al. Stability of undiluted and diluted adenosine at three temperatures in syringes and bags. Am J Health Syst Pharm 1998;55(5):466-70. [PMID 9522931]
  • Kaltenbach M, Hutchinson DJ, Bollinger JE, et al. Stability of diluted adenosine in polyvinyl chloride infusion bags. Am J Health Syst Pharm 2011;68(16):1533-6. [PMID 21817085]
  • Lopez-Palop R, Saura D, Pinar E, et al. Adequate intracoronary adenosine doses to achieve maximum hyperaemia in coronary functional studies by pressure derived fractional flow reserve: a dose response study. Heart 2004;90(1):95-6. [PMID 14676256]
  • Choi SC, Yoon SK, Kim GW, et al. A convenient method of adenosine administration for paroxysmal supraventricular tachycardia. J Korean Soc Emerg Med 2003;14(3):224-7.
  • Helleman K, Kirpalani A, Lim R. A Novel Method of Intraosseous Infusion of Adenosine for the Treatment of Supraventricular Tachycardia in an Infant. Pediatric Emerg Care 2017;33(1):47-8. [PMID 28045841]

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