Clinical Guidelines (Nursing)

Adrenaline and fluid bolus administration in resuscitation


  • Introduction

    The Australian Resuscitation Council recommends the administration of Adrenaline and 0.9% Sodium Chloride bolus as treatment in the event of a cardiac arrest for Basic Life Support (BLS) or Advanced Life Support (ALS) 

    NB-this guideline does not include BLS associated within neonatal inpatients cared for within the Butterfly unit within the Royal Children’s Hospital


    Aim

    The purpose of this clinical guideline is to describe how to draw up and administer intravenous (IV) or intraosseous (IO) adrenaline and fluid in a resuscitation situation.


    Definition of terms 

    • IV - Intravenous
    • IO - Intraosseous
    • Endorsed Clinicians - appropriately endorsed Registered Nurses, Doctors or Pharmacists.
    • Cardiac arrest –.sudden and unexpected stoppage of effective heart action. Either the periodic impulses that trigger the coordinated heart muscle contractions cease or ventricular fibrillation or flutter occurs in which the individual muscle fibres have a rapid twitching. (http://medical-dictionary.thefreedictionary.com/cardiac). Please refer to Basic Life Support Guidelines for first line management of paediatric cardiac arrest (http://www.resus.org.au/guidelines/)  


    Procedure: Adrenaline 

    • 1:10 000 IV/IO for use in emergency resuscitation
    • 0.1mL/kg of 1:10 000 Adrenaline = 10mcg/kg, (Maximum single dose of 1mg) 
      OR
      0.01mL/kg of 1:1000 Adrenaline =10mcg/kg (Recommend drawing up the whole 1mL in 1:1000 adrenaline concentration vial and dilute with 9mL 0.9% Sodium Chloride for injection so 0.1mL/kg dosage (10mcg/kg) is always administered.
    • Adrenaline dosage must be:

    Equipment

    • 1 x Vial 1:10 000 Adrenaline undiluted 
             (May need further vials depending on patient size and if repeated doses are required)
    • 1 x 10mL luer lock syringe
    • 1 x blunt drawing up needle
    • 1 x 3 way tap
    • 2 x drug labels
    • 2 x 1, 3 & 5ml syringe depending on size of patient and dosage required
    • Red caps
    • Alcohol wipes


    Procedure

    • Draw up the entire 10mL ampoule of 1:10,000 Adrenaline into a 10mL luer lock syringe with a blunt needle. (Double check with another endorsed clinician and label clearly as per RCH drug labelling guidelines)
    • Attach a 3 way tap to the10mL syringe. (see Figure 1)
    • Attach the appropriate size syringe for the required adrenaline dose to 3 way tap to draw up adrenaline (1mL, 3mL or 5mL). Label syringes clearly and place in silver drug tray on Resuscitation trolley ready for use as required
    • Document any administered drug doses as given on resuscitation chart and MAR as ordered by Doctor and signed by 2 Registered Clinicians.

      (NB:if the above process is leading to any delay in immediate access to adrenaline dose then an initial dose can be drawn from the vial and then the remainder of the vial drawn up as described above).

    Adrenaline

    Figure 1. Example of how to draw up adrenaline

    • Check patency of IV cannula/ IO with 0.9% Sodium Chloride.
    • Ensure the The Six Rights of Drug Administration as described in the medication Management Procedure are adhered to. 
    • Following the protocol, administer prescribed dose of adrenaline once via IV/IO route followed by 3-5mLl 0.9% Sodium Chloride. If adrenaline is not required urgently place red bung on the end of the syringe and leave in silver drug tray on emergency trolley.

    Procedure: 0.9% sodium chloride

    Dosage

    • If hypovolaemia is suspected as the cause of cardiorespiratory arrest, intravenous or intraosseous crystalloid may be used initially for resuscitation] as a bolus of 20mL/kg. Additional boluses of crystalloid or colloid solution should be titrated against the response. (ARC/ANZCOR Guideline 12.4 January 2016). http://www.resus.org.au/guidelines/  
    • The recommended standard fluid resuscitation dose is 20mL/kg of 0.9% Sodium Chloride followed by an additional dose if required.
    • Fluid bolus and volume must be ordered by Medical staff (initially a verbal order)


    Patients < 20kg (See Figure 2)

    Recommended Equipment required:

    • 500mL bag 0.9% Sodium Chloride (0.9% saline)
    • Green burette (Dosifix 150mL burette macro dropper)
    • 2 x 3-way-taps
    • 30 mL syringe
    • Alcohol wipes


    Procedure

    • Connect both 3-way-taps to patient end of Dosifix green burette line. 
    • Attach 30mL syringe to 3 way tap furthest away from the patient for fluid administration.
    • Ensure rolling clamps are on
    • Endorsed clinician double check the 500mL 0.9% Sodium Chloride bag with second endorsed clinician
    • Spike 0.9% sodium chloride bag, open clamps on burette line and prime line (including 3 way taps)
    • Attach to patient using non-touch technique  after cleansing IV/IO access with alcohol wipe and administer as ordered. Bolus can be administered via gravity (not IO), or by using the 30mL syringe attached to the 3-way-tap - the fluid is drawn from the burette then manually infused into the patient’s access site (once each syringe is administered to the patient the volume is announced to the Leader or scribe)
    • Administer as ordered by medical staff.

    Sodium Chloride

    Figure 2. Dosifix Burette 3 way tap configuration for Fluid Administration

    Patients > 20kg (See Figure 3)

    Recommended equipment required:

    • 500 mL bag 0.9% Sodium Chloride (0.9% saline)
    • Rapid Infuser Hand Pump set (TUTA) 
    • 2 x 3-way-taps
    • 30mLsyringe
    • Alcohol wipes

    Procedure

    • Connect both 3-way-taps to patient end of hand pump line. 
    • Attach 30mLsyringe to 3 way tap furthest away from the patient for fluid administration.
    • Ensure hand pump line clamps are on.
    • Endorsed clinician double check the 500mL 0.9% Sodium Chloride bag with second endorsed clinician
    • Spike bag 0.9% Sodium Chloride bag, invert fluid chamber on line, open clamp and prime line including 3 way taps
    • Attach to patient using a non-touch technique  after cleansing IV/IO access with alcohol wipe and administer as ordered. Fluid can be rapidly infused by squeezing fluid chamber on hand pump line with hand. Volume of fluid delivered is assessed by observing the volume lines on the 500mL Sodium Chloride 0.9% bag. Bolus can be also be administered by using the 30mL syringe attached to the 3-way-tap-fluid is drawn from the burette into the syringe then manually infused into patient’s access site (once each syringe is administered to the patient the volume is announced to the Leader or Scribe).
    • Administer as ordered by Medical staff.

    Resus fig3

    Figure 3. Rapid Infuser Hand Pump set (TUTA) and 3 way tap configuration and fluid administration 

    NB:if the above process is leading to any delay in immediate access to a Fluid bolus then an initial bolus of 30mL 0.9% Sodium Chloride can be drawn from the individual plastic saline ampoules with blunt needle until the line is primed and connected to the patient’s IV\IO or access line and then administered as described above ( see Figure 4).

    Resus fig4
    Figure 4: 30mL syringe with 0.9% Sodium Chloride



    Acute management

    Administration/application of intervention

    • Responsibilities of administration for Endorsed Clinicians:
    • Ensure patency of IV cannula before administering fluid bolus. Ensure the cannula site can be visualised during fluid bolus.
    • Ensure fluid bolus has been ordered by Medical staff (can be verbally in an emergency).
    • During administration of fluid monitor IV cannula.
    • Continue to monitor fluid bolus administration until completed. 
    • Once completed confirm the volume has been delivered to the Medical staff member or Team Leader and Scribe.
    • Document fluid bolus as per RCH documentation policy.
    • Document Patient observations


    Special considerations

    • infection control
    • patient safety alerts
    • potential adverse events


    Companion documents

    1. http://www.rch.org.au/policy/policies/Medication_Management/
    2. http://www.rch.org.au/policy/policies/Aseptic_Technique/
    3. http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/
    4. http://www.rch.org.au/clinicalguide/guideline_index/Resuscitation/
    5. http://www.rch.org.au/policy/policies/Central_Venous_Access_Device_Management/ 
    6. http://www.rch.org.au/policy/policies/Hand_Hygiene/
    7. Adrenaline and Fluid Bolus Administration in response to an emergency


    Links

    1. ARC guidelines http://www.resus.org.au
    2. ‘First 3 Minutes’ Program http://www.rch.org.au/MedEd/EducationPrograms/First3Minutes/


    Evidence table

    Click here to view the evidence table for this guideline


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Jenny Hough, Nurse Educator, Resuscitation Programs, and approved by the Nursing Clinical Effectiveness Committee. First published May 2016.