Adenosine and Pediatric Supraventricular Tachycardia in the Emergency Department: Multicenter Study and Review

doi:10.1016/S0196-0644(99)70392-6

Annals of Emergency Medicine

Volume 33, Issue 2, February 1999, Pages 185-191

https://doi.org/10.1016/S0196-0644(99)70392-6 Get rights and content

Abstract

Study objective: To determine the frequency of successful cardioversion and the adverse effects of adenosine treatment in pediatric emergency department patients with supraventricular tachycardia (SVT). Methods: This was a multicenter descriptive study with both prospective (convenience sample) and retrospective (chart review) patient entry. The setting was 7 urban pediatric EDs with a yearly census range of 22,000 to 70,000 visits. Pediatric patients 18 years of age and younger who received intravenous adenosine for presumed SVT were eligible. Results: Six investigators from 7 pediatric EDs entered 82 patients with 98 presumed SVT episodes (52 prospective and 46 retrospective) into the study. Twenty-five episodes occurred in children younger than 1 year of age. Eight patients had congenital heart disease, 59 had a history of SVT, 43 were taking cardiac medications (digoxin in 27), 13 had a history of asthma, and 25 presented in compensated cardiogenic shock. A total of 193 intravenous doses of adenosine were administered; doses were classified as low (<.1 mg/kg [n=18]), medium (.1 to <.2 mg/kg [n=116]), or high (≥.2 mg/kg [n=59]). The dose range was .03 to .5 mg/kg, and only 2 doses were higher than .3 mg/kg. A total of 95 patient-events were determined to be SVT, all but 5 of which were atrioventricular (AV) node–dependent; 3 events were ventricular tachycardia. The overall cardioversion success rate of adenosine was 72% (71/98), and that for AV node–dependent SVT was 79% (71/90). Cardioversion was successful for 4 patient-events at a low dose, 44 at a medium dose, and 23 at a high dose of adenosine. Adverse effects occurred in 22 patients, and no patient had bronchospasm or hemodynamically significant arrhythmia. Conclusion: Intravenous administration of adenosine led to successful cardioversion in 72% of pediatric ED patient-events that were presumed to be SVT. A dose range of .1 to .3 mg/kg was found to be most effective. Adenosine was not associated with significant adverse effects.

[Pediatric Emergency Medicine Collaborative Research Committee, Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K: Adenosine and pediatric supraventricular tachycardia in the emergency department: Multicenter study and review. Ann Emerg Med February 1999;33:185-191.]

Section snippets

INTRODUCTION

Supraventricular tachycardia (SVT) occurs in 1 of 250 to 1 of 1,000 children, making it the most common arrhythmia in the pediatric population. Adenosine is an endogenous nucleoside that transiently blocks atrioventricular (AV) conduction in the heart.1, 2, 3, 4, 5 Almost 90% of SVT in children is based on a re-entrant mechanism.⁶ For these reasons, adenosine should be effective for the termination of most pediatric SVT episodes. Reports of the use of adenosine in children are limited to

MATERIALS AND METHODS

Through the Collaborative Research Committee, Emergency Medicine Section, American Academy of Pediatrics, 6 of 23 pediatric emergency medicine physician committee members offered to participate in this study. The study protocol was approved by the review board of each center at which patients were entered prospectively. Consent beyond the standard consent for treatment in the ED was waived because adenosine is the drug of choice for SVT.

Children from birth to 18 years of age who received

RESULTS

Six pediatric emergency medicine physicians from 7 urban pediatric EDs (annual census, 22,000 to 70,000 visits) participated. There were 82 patients and a total of 98 presumed SVT events. One patient had 5 events, 3 patients had 3 events each, and 6 patients had 2 events each. There were 52 prospective and 46 retrospective patient-events. The range of patient entry dates for each investigator is presented in Table 1.

. Method of patient entry and dates.

Investigator	Patients Entered

DISCUSSION

The overall success rate for conversion of 98 presumed SVT events in 82 pediatric patients treated in the ED was 72%. This compares with a rate of 77% (90/117) reported by Till et al¹⁰ in 50 hospitalized pediatric patients (1 to 17 years of age). Till et al reported an 86% (88/102) success rate for AV node–dependent SVT, compared with 79% in our study. Two ED studies of adult patients showed overall success rates of 54% and 85% and AV node–dependent SVT success rates of 85% and 96%.16, 17 Five

Acknowledgements

We thank Alice Sather for her help in the preparation of this manuscript.

References (32)

CJ Garratt et al.
Comparison of adenosine and verapamil for termination of paroxysmal junctional tachycardia
Am J Cardiol
(1989)
ED Overholt et al.
Usefulness of adenosine in the treatment of supraventricular tachycardia in infants and children
AF Rossi et al.
Adenosine in altering short and long term treatment of SVT in infants
Am J Cardiol
(1989)
PC Dorostkar et al.
Failure of adenosine to terminate supraventricular tachycardia in neonates
Am J Cardiol
(1993)
CA Marco et al.
Adenosine for the treatment of supraventricular tachycardia in the ED
Am J Emerg Med
(1994)
CB Cairns et al.
Intravenous adenosine in the emergency department management of paroxysmal supraventricular tachycardia
Ann Emerg Med
(1991)
JL McCabe et al.
Intravenous adenosine in the prehospital treatment of paroxysmal supraventricular tachycardia
Ann Emerg Med
(1992)
CD Madsen et al.
A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting
Ann Emerg Med
(1995)
R Furlong et al.
Intravenous adenosine as first-line prehospital management of narrow-complex tachycardias by EMS personnel without direct physician control
Am J Emerg Med
(1995)
M Lozano et al.
Effect of adenosine on the management of supraventricular tachycardia by urban paramedics
Ann Emerg Med
(1995)

M Gausche et al.

Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia

Ann Emerg Med

(1994)

FR Melio et al.

Successful conversion of unstable supraventricular tachycardia to sinus rhythm with adenosine

Ann Emerg Med

(1993)

JE Crosson et al.

Therapeutic and diagnostic utility of adenosine during tachycardia evaluation in children

Am J Cardiol

(1994)

KK Burkhart

Respiratory failure following adenosine administration

Am J Emerg Med

(1993)

ME Herbert et al.

Adenosine in wide-complex tachycardia

Ann Emerg Med

(1997)

AJ Camm et al.

Adenosine and supraventricular tachycardia

N Engl J Med

(1991)

Cited by (112)

Delayed adenosine therapy is associated with the refractory supraventricular tachycardia in children
2020, American Journal of Emergency Medicine
Citation Excerpt :
The overall sinus conversion rate with adenosine approximates the known rates ranging from 72% to 77% [2,3]. The sinus conversion rate with 1 dose and the mean total dose were slightly higher than the values of 35%–36% [3,9] and 100–200 μg/kg [5,9,10] previously reported, respectively. This discrepancy supports the need for a higher first dose of adenosine [5].
To study the association of time intervals on adenosine therapy with the occurrence of refractory supraventricular tachycardia (SVT) in children.
We reviewed 334 episodes of presumed SVT requiring adenosine in children (<18 years) who visited 4 academic hospital emergency departments (EDs) from July 2013 through June 2017. Refractory SVT was defined as an SVT episode persisting after 2 doses of adenosine. Clinical and electrocardiographic findings, and symptom-to-adenosine (symptom-to-ED plus ED-to-adenosine) time of refractory and responsive SVT episodes were compared. Multivariable logistic regression was performed to identify factors associated with the occurrence of refractory SVT.
Of 211 SVT episodes, 42 episodes of refractory SVT (19.9%) were noted (overall sinus conversion rate, 79.6%). The refractory episodes were associated with a higher frequency of known structural heart diseases (9.5% vs. 1.8%; P = 0.030) and a longer median ED-to-adenosine time (15.5 vs. 11.0 min; P = 0.018). The association of the ED-to-adenosine time with refractory SVT remained significant after adjustment (for increment of 1 min; aOR, 1.02; 95% CI, 1.007–1.04).
Delayed adenosine therapy is associated with the occurrence of refractory SVT in children, supporting the need for prompt adenosine therapy.
Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team
2020, Anales de Pediatria
Determinar la frecuencia de taquicardia paroxística supraventricular (TPSV) como motivo de traslado interhospitalario en la edad pediátrica, describir la forma de presentación clínica, evolución y tratamiento, y factores de riesgo de presentar compromiso hemodinámico y proponer un protocolo de manejo específico para el transporte.
Estudio retrospectivo observacional de los pacientes atendidos en el Sistema de Emergencias Médicas Pediátricas (SEM-P) del Hospital Vall d’Hebron entre enero 2005 y junio 2017.
De un total de 7.348 traslados, 67 fueron pacientes con TPSV (0,9%). Edad mediana de 57 días de vida (2 h a 18 años). Catorce pacientes (20,9%), presentaban signos de compromiso hemodinámico en el momento del diagnóstico. La edad ≤ 1 año fue el único factor de riesgo independiente para presentar compromiso hemodinámico al diagnóstico con un OR de 10,2 (IC 95%: 1,2-89,9; p: 0,004). La mayoría de pacientes revirtieron con las intervenciones del hospital emisor, exceptuando la intubación y la cardioversión eléctrica, realizadas más frecuentemente por el equipo de trasporte (ET). El tiempo mediano de estabilización fue de 35 min (9-169), con un tiempo mediano de traslado de 30 min (9-165).
El transporte de pacientes pediátricos con TPSV es poco frecuente, pero puede requerir un manejo altamente especializado. La edad ≤ 1 año es el único factor de riesgo independiente para presentar compromiso hemodinámico. La coordinación entre el equipo del hospital emisor y el ET es de gran importancia para un buen resultado asistencial.
The aim of this study is to establish the incidence of supraventricular tachycardia (SVT) as a main reason for between-hospital transfer in children, as well as to describe the clinical presentation, prognosis and treatment, risk factors presenting with haemodynamic compromise, and to propose a specific management protocol for the transport.
A retrospective observational study was conducted on all patients with supraventricular tachycardia transferred by the Hospital Vall d’Hebron Sistema de Emergencias Médicas Pediátricas (SEM-P) between January 2005 and June 2017.
During the study period, 67 (0.9%) patients (out of a total number of 7348 transfers) suffered from SVT. The median age was 57 days (2 hours-18 years old). There was clinical evidence of cardiogenic shock on admission in 14 (20.9%) patients. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission, with an OR of 10.2 (95% CI: 1.2-89.9; P=.004). The majority of patients could be treated appropriately by the local hospital team, except for oral intubation and cardioversion that were performed mainly by the transport team on arrival at the local hospital. Median stabilisation time was 35 minutes (9-169), and median total transport time was 30 minutes (9-165).
Only 0.9% of transport cases are due to SVT, but this can be highly demanding as patients can be critically ill. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission. Coordination between the local and the transport teams is crucial for a good clinical outcome.
Management of Pediatric Chest Pain, Palpitations, Syncope, and Murmur Presenting to the Emergency Department
2018, Clinical Pediatric Emergency Medicine
Chest pain, palpitations and syncope are amongst the most common symptoms presenting to the emergency department (ED). A finding of a murmur, although rare to present as primary cause for ED visit, can often be an associated finding noted during the evaluation. Although these symptoms can be very alarming to patients and parents, they are infrequently associated with significant cardiac disease. Although the cardiac etiologies for these common symptoms are rare, these cardiac conditions can sometimes be life threatening. This review examines these presenting symptoms of chest pain, syncope and palpitations or the finding of murmur for possible differential diagnoses.
Adenosine Administration With a Stopcock Technique Delivers Lower-Than-Intended Drug Doses
2018, Annals of Emergency Medicine
Citation Excerpt :
A prospective study to determine the optimal adenosine dose effective in supraventricular tachycardia showed a mean effective dose of 185.3 μg/kg (SD 81.0 μg/kg) (median 200 μg/kg) in 110 episodes of supraventricular tachycardia.7 Similarly, in another investigation, an initial adenosine dose greater than 0.1 mg/kg showed improved efficacy compared with doses less than 0.1 mg/kg (38% versus 22%), and significantly more doses of adenosine were required for cardioversion when a low initial dose was used.5 Higher doses of adenosine, up to 0.3 mg/kg, appear to be generally safe.5,9,10
Adenosine administration with a stopcock is the recommended treatment for pediatric patients with acute supraventricular tachycardia. Recent reports suggest that many infants do not respond to the first dose of adenosine administered. Our aim is to determine whether administration of adenosine with a stopcock delivers lower-than-expected drug doses in patients weighing less than 10 kg, corresponding to weights of infants.
We developed an in vitro model of adenosine delivery. Doses of adenosine corresponding to weights 2 to 25 kg were calculated, using a dose of 0.1 mg/kg, and administered through one port of a stopcock. Distilled water was administered through the second port. The adenosine concentration of the output was measured with mass spectrometry and results were confirmed with spectrophotometry of Evans blue.
The mean doses of adenosine delivered through the stopcock increased as weight increased. The mean dose of adenosine delivered was 0.08 mg/kg for weights 2 to 9 kg and 0.1 mg/kg for weights 10 to 25 kg (95% confidence interval for difference of means –0.03 to –0.009). The median dose of adenosine delivered was 0.07 mg/kg (interquartile range [IQR] 0.06 to 0.07 mg/kg), 0.09 mg/kg (IQR 0.08 to 0.09 mg/kg), and 0.1 mg/kg (IQR 0.09 to 0.1 mg/kg) for weights 2 to 5, 6 to 9, and 10 to 25 kg, respectively (rank difference=100; P<.05 for 2 to 5 kg versus 10 to 25 kg). Similar results were obtained with spectrophotometry.
Administration of adenosine through a stopcock delivers doses lower than intended in patients weighing less than 10 kg, which may account for the decreased response of infants to the first dose of adenosine.
Cardiopulmonary resuscitation (CPR) in children with heart disease
2018, Critical Heart Disease in Infants and Children
Over the past two decades survival from pediatric cardiac arrest has improved dramatically, particularly in the in-hospital setting, from 15% to nearly 50%. The reasons for this are multifactorial and include but are likely not limited to the use of ECPR, personalizing the care delivered to the child's age and also the child's underlying cardiac anatomy and physiology, and applying a multitude of approaches to improving the quality of care we deliver. Teams are now systematically addressing the quality of cardiopulmonary resuscitation (CPR) delivered during the event with real-time feedback with bedside devices and quality CPR coaches, postevent debriefing, and meticulously managing the post–cardiac arrest care period. Unfortunately, there is evidence of great variability between hospitals, suggesting there are still lives to be saved. In the upcoming decades we need to continue to explore physiologic targets to optimize coronary and cerebral perfusion while minimizing harm from compressions, use human factors to improve team dynamics and room ergonomics, refine approaches to post–cardiac arrest care, and improve our ability to prognosticate on outcomes. Although avoiding a cardiac arrest is always best, we now know that many lives can be saved with exquisite CPR, and we must continue to focus on optimizing outcomes for these most vulnerable of patients.
Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia
2017, Journal of Pediatrics
To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT).
Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined.
We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ² = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT.
In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.

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^☆: Address for reprints: Joseph D Losek, MD, Children’s Hospitals and Clinics—St Paul, 345 North Smith Avenue, St Paul, MN 55102; 651-220-6914.

^☆☆: 47/1/94880

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Adenosine and Pediatric Supraventricular Tachycardia in the Emergency Department: Multicenter Study and Review☆,☆☆

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Cardiol

Am J Emerg Med

Ann Emerg Med

Adenosine and supraventricular tachycardia

N Engl J Med