Policy Number: 4:52 Section: Care Of Patient Date Written: May 1996 Date(s) Revised: 4/97, 7/98, 10/01, 6/04 Date(s) Reviewed: Reviewed/Approved by: Dept/Cmt Nuc Med Dir.

Date 7/04

Final Approval: _____________________________ ____ VP Operations, Chief Nursing Officer Date Distribution: Diagnostic Imaging, Cardiac Services

DOBUTAMINE CARDIAC PERFUSION SCAN POLICY: The RN, under physician supervision, will assess, administer medication, and monitor the patient undergoing cardiac testing. PURPOSE: To administer medication to evaluate the status of myocardiac perfusion. SUPPORTIVE DATA: 1. 2. 3.

4.

There are many patients with known or suspected coronary artery disease who cannot exercise on a treadmill and require pharmacologic induced stress testing. Dobutamine drip graph and THR percentage chart accompany this procedure to assist staff with calculations. 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 - 40 mcg/kg/min 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 IHC chart Dobutamine Stress Test worksheet Dobutamine Protocol for use of Esmolol, Atropine, and Lidocaine

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 physician and written consent obtained. All patients are to have an IV started(preferably in the R/arm) with 250 D5W. Patient should be connected to monitor to obtain pulse rate, and blood pressure for baseline assessment. 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. Have Esmolol, Atropine, and Lidocaine dosages calculated and ready for use Dobutamine will be administered as outlined on the Dobutamine drip graph or as ordered by the physician.

4. 5.

6.

7. 8.

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 cardiotracer is injected or as ordered by the physician. 11. Record O2 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 after re-injection

Key Points 1.

The pharmacy will mix the Dobutamine - 50 mg Dobutamine in 50 D5W or 1 mg/ml and deliver to nuclear med. upon request. 2. The THR is 85% of max. per IHC chart. The formula used to figure percentages: 220 - age = 100% 200% X ___ % div. by 100 = ___ % *The physician may request a higher % THR.

4. 5.

A T-connector should be used to provide an additional port for the injection of a cardiotracer. Baseline assessment can be used for future reference.

6.

The Cardiac Services Department will provide an EKG technician. A timer may be helpful for the technician.

7.

Refer to the Dobutamine protocol for usage guidelines. The nurse will calculate the amount of Dobutamine (ug/kg/min) according to the patient's weight using the Dobutamine drip graph. The cardiotracer will be injected at the physicians request (usually at peak HR or at the 40 mcg setting). The Dobutamine drip will be piggybacked to the main line IV. An infusion pump must be used in the administration of the Dobutamine.

8.

9.

12. The technologist will discontinue the heplock after imaging has been completed.

DOCUMENTATION: Patient assessment is documented on the Dobutamine Stress Test Worksheet. EKG's are recorded by the treadmill tech Entire chart will be kept on file in the Cardiac Services Charges will be made by Cardiac Services and 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

Dobutamine Cardiac Perfusion Scan – Page 3 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

50

15

30

60

90

120

55

16.5

33

66

99

132

60

18

36

72

108

144

65

19.5

39

78

117

156

70

21

42

84

126

168

75

22.5

45

90

135

180

80

24

48

96

144

192

85

25.5

51

102

153

204

90

27

54

108

162

216

95

28.5

57

114

171

228

100

30

60

120

180

240

105

31.5

63

126

189

252

110

33

66

132

198

264

115

34.5

69

138

207

276

120

36

72

144

216

288

125

37.5

75

150

225

300

130

39

78

156

234

312

135

40.5

81

162

243

324

140

42

84

168

252

336

Dobutamine Cardiac Perfusion Scan – Page 4 STRESS TESTS - PERCENTAGES Age 27 75% = 145 80% = 154 85% = 164 90% = 174 95% = 183 100% = 193

Age 28 75% = 144 80% = 154 85% = 163 90% = 173 95% =182 100% = 192

Age 29 75% = 143 80% = 153 85% = 162 90% = 172 95% = 181 100% = 191

Age 30 75% = 142 80% = 152 85% = 161 90% = 171 95% = 180 100% = 190

Age 31 75% = 142 80% = 151 85% = 161 90% = 170 95% = 180 100% = 189

Age 32 75% = 141 80% = 150 85% = 160 90% = 169 95% = 179 100% = 188

Age 33 75% = 140 80% = 149 85% = 159 90% = 168 95% = 177 100% = 187

Age 34 75% = 140 80% = 149 85% = 158 90% = 167 95% = 177 100% = 186

Age 35 75% = 139 80% = 148 85% = 157 90% = 167 95% = 176 100% = 185

Age 36 75% = 138 80% = 147 85% = 156 90% = 166 95% = 175 100% = 184

Age 37 75% = 137 80% = 146 85% = 156 90% = 165 95% = 174 100% = 183

Age 38 75% = 136 80% = 145 85% = 155 90% = 164 95% = 173 100% = 182

Age 39 75% = 136 80% = 145 85% = 154 90% = 163 95% = 172 100% =181

Age 40 75% = 135 80% =144 85% =153 90% =162 95% =171 100% =180

Age 41 75% = 134 80% =143 85% =152 90% =161 95% =170 100% =179

Age 42 75% = 133 80% =142 85% =151 90% =160 95% =169 100% =178

Age 43 75% = 132 80% =141 85% =50 90% =159 95% =168 100% =177

Age 44 75% = 131 80% =140 85% =149 90% =158 95% =167 100% =176

Age 45 75% = 130 80% = 139 85% = 148 90% = 157 95% = 166 100% = 175

Age 46 75% = 129 80% = 138 85% = 147 90% = 156 95% = 165 100% = 174

Age 47 75% = 128 80% = 137 85% = 146 90% = 155 95% =164 100% = 173

Age 48 75% = 129 80% = 138 85% = 146 90% = 155 95% = 164 100% = 172

Age 49 75% = 128 80% = 137 85% = 146 90% = 154 95% = 163 100% = 171

Age 50 75% = 128 80% = 136 85% = 145 90% = 153 95% = 162 100% = 170

Age 51 75% = 127 80% = 135 85% = 144 90% = 152 95% = 161 100% = 169

Age 52 75% = 126 80% = 134 85% = 143 90% = 151 95% = 160 100% = 168

Age 53 75% = 125 80% = 133 85% = 142 90% = 150 95% = 159 100% = 167

Age 54 75% = 124 80% = 132 85% = 141 90% = 149 95% = 158 100% = 166

Age 55 75% = 123 80% = 131 85% = 140 90% = 148 95% = 157 100% = 165

Age 56 75% = 122 80% = 130 85% = 139 90% = 147 95% = 156 100% = 164

Age 57 75% = 121 80% = 129 85% = 138 90% = 146 95% = 155 100% = 163

Age 58 75% = 120 80% = 128 85% = 137 90% = 145 95% = 154 100% = 162

Age 59 75% = 119 80% = 127 85% = 136 90% = 144 95% = 153 100% = 161

Age 60 75% = 120 80% = 128 85% = 136 90% = 144 95% = 152 100% = 160

Age 61 75% = 119 80% = 127 85% = 135 90% = 143 95% = 151 100% = 159

Age 62 75% = 119 80% = 126 85% = 134 90% = 142 95% = 150 100% = 158

CONTINUED

Dobutamine Cardiac Perfusion Scan – Page 5 STRESS TESTS - PERCENTAGES - continued Age 63 75% = 118 80% = 126 85% = 133 90% = 141 95%= 149 100% = 157

Age 64 75% = 117 80% = 125 85% = 133 90% = 140 95% = 148 100% = 156

Age 65 75% = 116 80% = 124 85% = 132 90% = 139 95% = 147 100% = 155

Age 66 75% = 115 80% = 123 85% = 131 90% = 139 95% = 146 100% = 154

Age 67 75% = 115 80% = 122 85% = 130 90% = 138 95% = 145 100% = 153

Age 68 75% = 114 80% = 122 85% = 129 90% = 137 95% = 144 100% = 152

Age 69 75% = 113 80% = 121 85% = 128 90% = 136 95% = 143 100% = 151

Age 70 75% = 113 80% = 120 85% = 128 90% = 135 95% = 143 100% = 150

Age 71 75% = 112 80% = 119 85% = 127 90% = 134 95% = 142 100% = 149

Age 72 75% = 111 80% = 118 85% = 126 90% = 133 95% = 141 100% = 148

Age 73 75% = 110 80% = 118 85% = 125 90% = 132 95% = 140 100% = 147

Age 74 75% = 110 80% = 117 85% = 124 90% = 131 95% = 139 100% = 146

Age 75 75% = 109 80% = 116 85% = 123 90% = 130 95% = 138 100% = 145

Age 76 75% = 108 80% = 115 85% = 122 90% = 130 95% = 137 100% = 144

Age 77 75% = 107 80% = 114 85% = 122 90% = 129 95% = 136 100% = 143

Age 78 75% = 107 80% = 114 85% = 121 90% = 128 95% = 135 100% = 142

Age 79 75% = 106 80% = 113 85% = 120 90% = 127 95% = 134 100% = 141

Age 80 75% = 105 80% = 112 85% = 119 90% = 126 95% = 133 100% = 140

Age 81 75% = 104 80% = 111 85% = 118 90% = 125 95% = 132 100% = 139

Age 82 75% = 104 80% = 110 85% = 117 90% = 124 95% = 131 100% = 138

Age 83 75% = 103 80% = 110 85% = 116 90% = 123 95% = 130 100% = 137

Age 84 75% = 102 80% = 109 85% = 116 90% = 122 95% = 129 100% = 136

Age 85 75% = 101 80% = 108 85% = 115 90% = 122 95% = 128 100% = 135

Age 86 75% = 101 80% = 107 85% = 114 90% = 121 95% = 127 100% = 134

Formula used to figure percentages: 220 - age = 100% 100% x ___% - 100 = ___% Example: 220 - 27 = 193 (100%) 193 x 75% - 100 = 144.75 or 145 is 75% 100% RATES AGE

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70 +

SED

198

196

193

191

189

187

185

182

180

178

176

TRAIN

192

189

186

185

182

180

178

176

173

171

169

85% RATES SED

168

167

164

162

161

159

157

155

153

151

150

TRAIN

163

161

158

157

155

153

151

150

147

145

144

Dobutamine Cardiac Perfusion Scan – Page 6 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 IVP - observe monitor closely. May repeat dose of .2 mg to maximum dose of 2.0 mg.

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 0.125 mg - 0.25 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.

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