Aims Provocation challenges are used to diagnose certain inherited life-threatening cardiac conditions; treatment can prevent malignant arrhythmias and sudden death. Provocation medications are administered to unmask pathognomic conduction characteristics on real-time electrocardiography. Pre-prepared rescue medications are administered should a ventricular arrhythmia be unintentionally provoked. These high-risk medications, in line with safety agency recommendations, should be delivered using smart-pump technology.1 They are also often unlicensed and expensive.2 We investigated the utilisation of smart-pumps and development of a guideline to optimise medicines management and safety of these procedures in an Irish tertiary paediatric hospital.
Methods Published literature and current practices, including those in other paediatric and adult hospitals in Ireland and the UK, were reviewed to ascertain appropriate dosing and administration in the paediatric population.3 4 Multi-disciplinary input from nursing, cardiology, pharmacy and biomedical engineering was sought in guideline development.
Results Evidence for such challenges in paediatrics is sparse. Suitable dosing was agreed and an indication-specific smart-pump drug library created. The ‘PCA Therapy’ module was employed to deliver repeated weight-based doses of the provocation medication (Ajmaline) in a controlled and timely manner; the rescue medication (Isoprenaline) was programmed as a continuous infusion. An auxillary calculator was developed in Microsoft Excel® to direct staff on preparation of both infusion solutions and bolus doses of medications to be manually administered (Magnesium and Isoprenaline). In 2017, relevant staff were trained, and the ‘Ajmaline Challenge’ guideline was approved and implemented in the Cardiac Catherisation Laboratory (CCL) and Cardiac Day Unit. Estimated cost savings of €19,400 were realised between January 2017 - October 2018 due to reduced wastage of unused medications. Further savings are likely due to decreased utilisation of the CCL.
Conclusion Multi-disciplinary collaboration and health technology can improve the safety and cost-effectiveness of high-risk cardiac diagnostic procedures in the paediatric setting. Similar processes for other provocation challenges are under development.
Institute for Safe Medication Practices, ISMP. 2018–2019 Targeted Medication Safety Best Practices for Hospitals 2018 [Available from: https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf [Accessed: June 2019]
European Commission. State of Paediatric Medicines in the EU - 10 years of the EU Paediatric Regulation 2017 [Available from: https://ec.europa.eu/health/sites/health/files/files/paediatrics/docs/2017_childrensmedicines_report_en.pdf [Accessed: June 2019]
McMillan MR, Day TG, Bartsota M, et al. Feasibility and outcomes of ajmaline provocation testing for Brugada syndrome in children in a specialist paediatric inherited cardiovascular diseases centre. Open Heart 2014;1:e000023.
Rolf S, Bruns HJ, Wichter T, et al. The ajmaline challenge in Brugada syndrome: diagnostic impact, safety, and recommended protocol. Eur Heart J. 2003;24:1104–12.
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