5.4
Aurora St Luke’s Medical Center:
Protocol For Dobutamine Stress Echo (DSE)
Procedure
- Dobutamine Stress echo is a procedure that utilizes medication to increase myocardial oxygen demands and cardiac ultrasound images to evaluate systolic dysfunction. Dobutamine stress echo is chosen as an alternative to exercise stress procedure due to the patient’s inability to reach his maximal exercise capacity.
- Indication
§ Known coronary artery disease
§ Suspected coronary artery disease
§ Evaluate degree of valvular stenosis
§ Evaluate degree of obstruction
- Equipment
§ Digital ultrasound unit with integrated
stress echo
§ Stress monitoring equipment
§ Echo supplies (Electrodes, Ultrasound,
Contrast)
§ IV kit
§ Infusion Pump
§ Emergency medical equipment
- Staff
§ Physician
§ Echo Technologist
§ Treadmill/Monitoring Technologist
- Medication/Contrast
§ IV solution (10cc Dobutamine mixed
with 40cc saline in a 60 cc syringe administered through a Graseby pump)
§ Beta blockers
§ Atropine sulfate
§ Nitroglycerin
§ Definity
- Pre Procedure Instruction
§ Light meal with liquid 4 hours prior
to procedure
§ Anti ischemic drug are not to be held per
physician’s request
§ Bring list of medication
§ Anti ischemic medications are not to
be taken per physician request
§ No smoking or alcohol after midnight
§ No lotion or powder on chest day of
test
§ Diabetics follow regular diabetic
routine for medication and eating
§ Bring inhaler if necessary
§ Equipment
- Guidelines for administering Dobutamine
§ Based on patient weight
§ Dobutamine will be administered in
stages
§ Stages 1 - 5mcg/kg/min for 3 minutes
(for viability)
§ Stages 2 - 10mcg/kg/min for 3 minutes
§ Stages 3 - 20mcg/kg/min for 3 minutes
§ Stages 4 - 30mcg/kg/min for 3 minutes
§ Stages 5 - 40mcg/kg/min for 3 minutes
§ Atropine is given when indicated by
monitoring physician
- Imaging Guidelines
§ 2 stage Dobutamine studies are
indicated when a patient has normal resting images
§ 4 stage Dobutamine studies are
indicated when a patient has resting wall motion abnormalities
§ Baseline images are obtained prior to
stage 1
§ Low dose images are obtained after the
infusion of 10mcg/kg/min of Dobutamine
§ Peak dose images are obtained when the
patient reaches 85 % of predicted target heart rate or as directed by physician
§ Peak dose images are obtained when the
patient heart rate is under 100 bpm or as directed by physician
§ Imaging consists of parasternal long
and short, apical 4 chamber, apical 2 chamber and apical long axis view
§ Monitoring physician and/or echo
technologist review and select the pre and post images
§ Use of contrast will be determined by
the echo technologist and administered by the monitoring or echo technologist
- Monitoring Guidelines
§ Baseline standing and supine 12 leads
ECG
§ Baseline standing and supine blood
pressure
§ 12 leads ECG at the end of each 3
minutes stage
§ Blood pressure 2 minutes into each
stage
§ ECG and blood pressure 6 minutes into
recovery or until baseline is reached
§ Pulse ox used per MD request
§ Monitoring physician is present
throughout procedure
- Absolute Indication For Termination Of Procedure
§ Acute MI or suspicion of a MI
§ Moderate to severe angina
§ A drop in systolic BP with increasing
workload accompanied by sign/symptoms
§ Serious arrhythmias ie Sustained VT or
increasing polymorphic PVC’s, A Fib uncontrolled, 2nd & 3rd
degree AV blocks
§ Unusual or severe dyspnea
§ Signs of poor perfusion, ie pallor,
cyanosis
§ Central nervous system symptoms ie
ataxia, confusion, etc
§ Inability to monitor ECG (technical
problems)
§ Patient inability to continue
- Relative Indication For Termination Of Procedure
§ Significant ECG changes from baseline
ie >2mm of horizontal or downward sloping ST segment depression
§ Any increasing angina
§ Physical or verbal manifestations of
severe fatigues and dyspnea
§ Hypertensive response ie Systolic
>260 mmHg Diastolic >115 mmHg
§ Less serious arrhythmias ie Non
Sustained VT
§ Exercise induced Bundle Branch Block
that cannot be distinguished from VT
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