Salbutamol - Intravenous

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the use of intravenous salbutamol.

Note: Intravenous salbutamol should only be used in discussion with clinicians who are familiar with its use and who have an understanding of doses, concomitant inhaled medications and required monitoring.

Medication

• Salbutamol is a β agonist that can be used intravenously in severe acute asthma in the Emergency Department or Paediatric Critical Care (PCC) Unit).

Actions

• Salbutamol acts on the β2 adrenoceptors in the smooth muscle of the bronchi causing bronchodilation.¹

Indications

• Acute severe asthma
• Inadequate response to continuous nebulised salbutamol

Contraindications

• Patients with known hypersensitivity to salbutamol or any component of the formulation.

Precautions

• Hypertension
• Hyperthyroidism
• Cardiovascular disease, susceptibility to QT prolongation
• Hypokalaemia
• Diabetes
• Glaucoma
• Seizure disorders
• Treatment with other sympathomimetic amines – may increase adverse effects (e.g. tremor, tachycardia, headache)⁸

Adverse effects

• Muscle tremors, especially of the hands
• Tachycardia
• Nausea and vomiting
• Headaches, agitation and hyperactivity
• Palpitations
• Feelings of warmth
• High doses can cause peripheral vasodilatation resulting in hypotension
• Overdose can result in chest pain, SVT and pulmonary hypertension
• Hypokalaemia
• metabolic acidosis
• Hyperglycaemia

Dosage

Intravenous Infusion:

Children 2 to 12 years up to 40kg

• Loading dose may be given at consultant’s discretion. 15microg/kg (max 300microg) over 10 minutes. ⁵
• Give continuous infusion at an initial rate of 1microg/kg/min. Adjust rate according to response, up to 5microg/kg/min (max 80microg/min). ^5,6

Preparation

• Peripheral line: Maximum concentration of 200microg/mL.⁷ Dilute 2.5mg/kg of salbutamol up to 500mL with a compatible fluid to give a solution where 12mL/hour is equivalent to 1microg/kg/min.
• Central line: May be administered undiluted if fluid restricted.⁷ Dilute 3mg/kg of salbutamol up to 50mL with a compatible fluid to give a solution where 1mL/hour is equivalent to 1microg/kg/min.

Children > 40kg:

• Loading dose may be given at consultant’s discretion. 200–300microg/dose over 1 minute.
• Continuous infusion at 5microg/min. Adjust rate according to response, up to 10– 20microg/min. ^5,6
• NOTE: For children > 40kg, the dose is in microg/min and NOT microg/KG/min.

Preparation

• Peripheral line: Maximum concentration of 200microg/mL⁷. Dilute 15mg of salbutamol up to 100mL with a compatible fluid to give a solution where 1mL/hour is equivalent to 2.5microg/minute.
• Central line: May be administer undiluted if fluid restricted⁷, i.e. a neat solution of 50mg in 50mL, where 1mL/hour is equivalent to 16.67microg/minute.

Administration

• Ideally concentrations greater than 200 microgram/mL should be infused via a central line but should not delay initial treatment in an emergency situation⁴
• Administer infusion via a syringe pump.
• Set volume to be infused on the syringe pump to prevent overdose.
• Always prime the line with the diluted salbutamol solution to prevent any delay in the patient receiving the medication.
• Note: There is little evidence on the concomitant use of inhaled salbutamol while patients are on an intravenous salbutamol infusion. Its use should be limited to the child who has severe/ life threatening asthma and in consultation with the on-call PCC Consultant.

Nurse special

• The patient will require 1:1 nursing care.
• Administer IV infusion via infusion pump.
• Continuous cardiac monitoring.
• 5 minutely observations for the first 10 minutes – heart rate, respiratory rate, blood pressure, oxygen saturations. Record on the observation and response tool. Document additional information on the Clinical Comments sheet.
• 15 minutely observations thereafter.
• Electrolyte monitoring at baseline, after 2 hours and then a minimum of 12 hourly¹
• Paediatric Critical Care review of all patients requiring IV salbutamol.
• Consider placing a second intravenous cannula (for further treatment as salbutamol is incompatible with many other drugs).

References

1. Starkey ES, Mulla H, Sammons HM, et al. Intravenous salbutamol for childhood asthma: evidence-based medicine? Archives of Disease in Childhood 2014; 99:873-877.
2. National Asthma Council Australia. Australian Asthma Handbook, Version 1.3. National Asthma Council Australia, Melbourne, 2017. Website. Available from: http://www.asthmahandbook.org.au
3. Australian Medicines Handbook, Pharmaceutical Society of Australia, Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, Royal Australian College of General Practioners. AMH children's dosing companion 2018.
4. Burridge N, Collard N, Symons K, Society of Hospital Pharmacists of Australia. Australian injectable drugs handbook [Internet]. Collingwood, Vic.: The Society of Hospital Pharmacist of Australia; 2018.
5. Australian Asthma Handbook: National Asthma Council Australia; 2021. Available from: http://www.asthmahandbook.org.au/
6. eTG Complete West Melbourne, VIC Australia: Therapeutic Guidelines Ltd; 2021. Available from: https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/CAHS/PCH.MED.Salbutamol.pdf
7. Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. The Lancet. 1997 1997 Feb 01 2018- 10-16;349(9048):301-5. PubMed PMID: 198990765; 9024371; 97176832; 03161671. English.
8. Rossi S, Pharmaceutical Society of Australia, Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, Royal Australian College of General Practitioners. Australian Medicines Handbook 2021. Available from: https://amhonline-amhnet-au.pklibresources.health.wa.gov.au/chapters/respiratory-drugs/drugs-asthma-chronicobstructive-pulmonary-disease/beta2-agonists/salbutamol

Endorsed by:	Executive Director, Medical Services	Date:	Oct 2021
		Review date:	Oct 2022

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