Mohd Farid

Mohd Farid

Friday, September 28, 2012

The Sonographer Attachment Programme At USA Report : Aurora St Luke's Echo Protocol =Dobutamine Stress Echo=


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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