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

• Cardiovascular disorders (including hypertension, ischaemic heart disease, heart failure, arrhythmias) – risk of cardiovascular adverse effects when administered intravenously.²
• High doses of intravenous and nebulised salbutamol may cause lactic acidosis. Increase in lactate levels may lead to dyspnoea and compensatory hyperventilation, which could be misinterpreted as a sign of asthma treatment failure. Monitor for elevated serum lactate levels.²
• Pre-existing hypokalaemia – may further decrease potassium levels. Correct hypokalaemia prior to salbutamol administration.³
• Hyperthyroidism – may stimulate thyroid activity, increase risk of cardiovascular adverse effects when given intravenously.^2,3
• Diabetes – risk of hyperglycaemia and ketoacidosis with high doses and concurrent administration of corticosteroids, monitor blood glucose levels.^2,3
• Treatment with other sympathomimetic amines – may increase adverse effects (e.g. tremor, tachycardia, headache).²
• Glaucoma – may elevate intraocular pressure, use with caution.³
• Seizure disorders – use with caution, beta-agonists may result in CNS stimulation/excitation.³

Adverse effects

The inhaled route has fewer systemic adverse effects compared to IV.

• Common: Tremor, palpitations, flushing, headache.
• Infrequent: Hyperglycaemia and hypokalaemia (high dose), tachycardia, muscle cramps, agitation, hyperactivity in children, insomnia.
• Rare: Paradoxical bronchospasm, hypersensitivity reactions, lactic acidosis. 

Dosage

Intravenous Infusion:

IV route should be considered if continuous nebulisation is not possible/effective, and only in the emergency department or intensive care/high dependency unit.

Intravenous - Children 6 months to 18 years:²

• Loading dose: 5 – 15 microg/kg (maximum 300 microg) over 10 minutes.
  • May be prescribed at consultant’s discretion. Continuous infusion may be started without a loading dose.
• Continuous infusion: Start at 1 microg/kg/MINUTE and adjust to response, up to 5 microg/kg/MINUTE (maximum 200 microg/MINUTE).
• To prepare 100 mg in 500 mL (200 microg/mL) standardised concentration: Discard 145 mL from a 500 mL bag of sodium chloride 0.9% (or other compatible fluid) and add 100 mg of salbutamol (20 x 5 mg/5 mL salbutamol ampoules) to bag.
  • At this concentration, 1 microg/kg/MINUTE is equivalent to 0.3 mL/kg/HOUR.
    • The maximum concentration for peripheral administration is 200 microg/mL.
    • Smaller total volumes may be prescribed.
    • Patients who are fluid restricted may be prescribed 25 mg in 50 mL, to be administrated via a central line only.

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.

Nursing considerations and monitoring

• The patient will require 1:1 nursing care.
• Monitor for signs of salbutamol toxicity – especially with frequent dosing, continuous nebulisation or intravenous salbutamol.
  • tachycardia,
  • tachypnoea
  • fine tremors.
• Observations
  • 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.
  • Serum potassium and electrolytes, blood glucose, acid/base balance (blood lactate) at baseline, after 2 hours and then a minimum of 12 hourly.¹
• 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. Rossi S, Pharmaceutical Society of Australia, Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, Royal Australian College of General Practitioners. Australian Medicines Handbook 2024. Available from: https://amhonline-amhnet-au.pklibresources.health.wa.gov.au/chapters/respiratory-drugs/drugs-asthma-chronicobstructive-pulmonary-disease/beta2-agonists/salbutamol 
3. UpToDate 2024. Available from: Albuterol (salbutamol): Pediatric drug information - UpToDate (health.wa.gov.au)
4. National Asthma Council Australia. Australian Asthma Handbook, Version 1.3. National Asthma Council Australia, Melbourne, 2017. Website. Available from: http://www.asthmahandbook.org.au
5. 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.
6. 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.
7. Australian Asthma Handbook: National Asthma Council Australia; 2021. Available from: http://www.asthmahandbook.org.au/
8. 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
9. 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.
10. 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 2024
		Review date:	Oct 2027

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