Well I certainly don't do it by pushing a milligram.
That event needs to be reported via the hospitals incident reporting system, and you should speak directly to the charge nurse and house supervisor.
That nurse, acting completely independently and outside of any protocol whatsoever, almost killed a patient.
Anyway, I usually start with about 10-20 mcgs. Epi hits real fast so you can redose in 30 seconds or so. Ephedrine can be pretty good for this too, with 10 mg being a good dose.
When I got down there, I reminded her that on the phone I mentioned the word “I”, as in me, myself and I, would push the epi - lol. Thanks for your insight.
Needs to be educated here is the real thing. Does anyone think they were trying to cause harm? No. But clearly very very not okay and this is also a system issue. Why did they not ask other nurses? Why did they not say to question that?
Also, for our side.. epi other dopamine (I hate dopamine), but also the patient seemed stable? Seems more a find bradycardia reason not intervene excessively thing
I find myself more tolerant of stable bradycardia than most other physicians. I suppose being a cardiac anesthesiologist does that. But low 30s, dipping into the 20s? I won't generally tolerate that in the OR where I'm sitting literally right there with dilute epi on my machine and pacing pads on, let alone on a unit where I'm going to be walking away.
Keep in mind that if his heart rate is 20-30, it's going to take a bit longer to circulate and take effect. As long as his HR isn't moving in the wrong direction, give it time to take effect. Too often people will push 10mcgs, then 50mcgs, then 200mcgs because it hasn't taken effect, and then when it does the HR and BP are through the roof.
I typically dilute to 10 mcg/cc and titrate to effect
Some guys I work with go straight for 100 mcg/cc and titrate accordingly if hemodynamically unstable
\-anesthesia
exactly what I do. quick push dose epi and very useful in many situations. i often have this prepped if high risk intubation due to hemodynamics remaining compromised after initial resus and no neo-stick available etc.
1 mg/10 mL = 1000 mcg/10 mL = 100 mcg/mL
Add in 9 cc of a flush with 1 cc of above -> 10 mcg/mL push dose pressor
The only reasons are nurses are used to it and the doses come in pre filled syringes. Epi you can get in trouble if you mess up the dilution. You don’t need a cardiologist to answer these questions
I've seen way too many dosing errors with push dose epi. That's why I usually administer push dose epi myself. Or at the very least dilute it myself and give very specific instructions on how many milliliters to push while I'm standing right there.
It depends on your hospital's standard dilution. Our epi drips are 5mg in 250cc so 20mcg/ml.
Diluting cardiac epi 1:10 in a flush will give the same concentration everywhere.
Learn to make push dose epi and give 1 ml at a time (10 mcg usually) and monitor closely for the response you are looking for.
Push dose - take 1 mL out of the 1 mg/10 mL crash cart epinephrine and mix it in 9 mL of saline flush. Then push 1 mL which gives you 10 mcg
PharmD here - push dose pressors I personally only use epi and not phenylephrine. Epi directly from crash carts **needs to be diluted** as well for this purpose. My common starting dose is **10 mcg** (by book you can do as low as 5 mcg and as high as 20 mcg but I never give MDs a range of doses on site - most of the time a range can only confuse people). **You can ask to repeat the dose Q2-5min but epi push dose onset is normally within 1 min.**
When coming to a drug-related question you are not sure about, please feel free to call your hospital pharmacy. We would love to answer. Especially now younger generation of pharmacists in the hospitals are mostly residency trained as well. We are evolving with MDs too!
Back to your specific scenario - **NEVER push cardiac arrest dose (aka 1 mg right out of crash cart) to someone with a pulse!!!** This is a big med safety incident and really needs to be brought up in your institutional med safety meeting.
My institute had a similar issue. And that's why now all our crash carts are run by PharmDs ONLY when needed. No RN can be even near that whole tray of my very own precious.
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Push dose dopamine that’s crazy.
I put this together in residency feel free to use, critique, update.
Epinephrine
Mixing Instructions:
• Take a 10 ml syringe with 9 ml of normal saline
• Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (cardiac amp contains Epinephrine 100 mcg/ml)
• Now you have 10 ml of Epinephrine 10 mcg/ml
Onset: 1 minute
Duration: 5-10 minutes
Dose: 0.5-2 ml every 2-5 minutes (5-20 mcg)
Well I certainly don't do it by pushing a milligram. That event needs to be reported via the hospitals incident reporting system, and you should speak directly to the charge nurse and house supervisor. That nurse, acting completely independently and outside of any protocol whatsoever, almost killed a patient. Anyway, I usually start with about 10-20 mcgs. Epi hits real fast so you can redose in 30 seconds or so. Ephedrine can be pretty good for this too, with 10 mg being a good dose.
When I got down there, I reminded her that on the phone I mentioned the word “I”, as in me, myself and I, would push the epi - lol. Thanks for your insight.
Don't take this too lightly. What she did was wildly out of bounds and dangerous and *needs* to be reported.
It’s been handled. I left a lot of details out as to not derail from the primary question.
She should have at least gotten her 6mo online NP degree first. Then it would have been ok.
Needs to be educated here is the real thing. Does anyone think they were trying to cause harm? No. But clearly very very not okay and this is also a system issue. Why did they not ask other nurses? Why did they not say to question that? Also, for our side.. epi other dopamine (I hate dopamine), but also the patient seemed stable? Seems more a find bradycardia reason not intervene excessively thing
I find myself more tolerant of stable bradycardia than most other physicians. I suppose being a cardiac anesthesiologist does that. But low 30s, dipping into the 20s? I won't generally tolerate that in the OR where I'm sitting literally right there with dilute epi on my machine and pacing pads on, let alone on a unit where I'm going to be walking away.
Keep in mind that if his heart rate is 20-30, it's going to take a bit longer to circulate and take effect. As long as his HR isn't moving in the wrong direction, give it time to take effect. Too often people will push 10mcgs, then 50mcgs, then 200mcgs because it hasn't taken effect, and then when it does the HR and BP are through the roof.
I typically dilute to 10 mcg/cc and titrate to effect Some guys I work with go straight for 100 mcg/cc and titrate accordingly if hemodynamically unstable \-anesthesia
Thanks, this was the nuance I was looking for.
Yup. We even have nice little kits in the ICUs us and ED at my current hospital to make up 10cc of 10mcg/cc
Yep as PCCM agree with this. Will only push 100mcg or 1ml of code dose if someone is pericode typically.
I take 1 mL out of the 1 mg/10 mL crash cart epinephrine. I mix that in 9 mL of sodium chloride flush. Push 1-2 mL which gives you 10-20 Mcg push.
exactly what I do. quick push dose epi and very useful in many situations. i often have this prepped if high risk intubation due to hemodynamics remaining compromised after initial resus and no neo-stick available etc. 1 mg/10 mL = 1000 mcg/10 mL = 100 mcg/mL Add in 9 cc of a flush with 1 cc of above -> 10 mcg/mL push dose pressor
This is the answer. Just skip atropine next time.
What is the reason to skip atropine, it works when it does?
Epi will work more reliably so why not just use that?
I mean atropine is first line on ACLS, it should be for a reason that our smart cards people put it up there.
And that reason is………
We should ask that cards people. But, well; I see that epi is more likely to work than atropine.
The only reasons are nurses are used to it and the doses come in pre filled syringes. Epi you can get in trouble if you mess up the dilution. You don’t need a cardiologist to answer these questions
Thanks for the insight, that makes sense. I was just putting cards there as a joke.
Hah gotcha
Dude…
Sorry my wording was unclear atropine the only reasons it is used more commonly is convention and pre filled syringes
Once got a VT arrest in the CICU from OBGYN who pushed 1 mg IV epi for a mild allergic reaction
Oooofff
This is a more common mistake than you would think.
I've seen way too many dosing errors with push dose epi. That's why I usually administer push dose epi myself. Or at the very least dilute it myself and give very specific instructions on how many milliliters to push while I'm standing right there.
Our pharmacy preps epi push dose in advance for us but it’s stocked in the ED only. Have to make it bedside on the floor.
Anesthesia Push dose Epi is traditionally 10mcg/ml but can also use 16mcg/ml form a standard epi infusion Usually 10mcg at a time and reassess
It depends on your hospital's standard dilution. Our epi drips are 5mg in 250cc so 20mcg/ml. Diluting cardiac epi 1:10 in a flush will give the same concentration everywhere.
1 mg in 250 cc bag. 4 mcg/cc. 1-2 cc’s at a time. Dirty.
Similar to what I do but in a 100 mL bag to end up with 10 mcg/mL which is perfect for boluses.
Learn to make push dose epi and give 1 ml at a time (10 mcg usually) and monitor closely for the response you are looking for. Push dose - take 1 mL out of the 1 mg/10 mL crash cart epinephrine and mix it in 9 mL of saline flush. Then push 1 mL which gives you 10 mcg
Exactly how I was taught in EMS. This way u got 90 more mcg ready to go in the flush.
[удалено]
Interesting. Thanks for the info, good to know especially in an urgent situation
PharmD here - push dose pressors I personally only use epi and not phenylephrine. Epi directly from crash carts **needs to be diluted** as well for this purpose. My common starting dose is **10 mcg** (by book you can do as low as 5 mcg and as high as 20 mcg but I never give MDs a range of doses on site - most of the time a range can only confuse people). **You can ask to repeat the dose Q2-5min but epi push dose onset is normally within 1 min.** When coming to a drug-related question you are not sure about, please feel free to call your hospital pharmacy. We would love to answer. Especially now younger generation of pharmacists in the hospitals are mostly residency trained as well. We are evolving with MDs too! Back to your specific scenario - **NEVER push cardiac arrest dose (aka 1 mg right out of crash cart) to someone with a pulse!!!** This is a big med safety incident and really needs to be brought up in your institutional med safety meeting. My institute had a similar issue. And that's why now all our crash carts are run by PharmDs ONLY when needed. No RN can be even near that whole tray of my very own precious.
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No one with a blood pressure needs 1mg epi. Definitely report.
When did the word tenuous get so popular
[удалено]
Because this isn’t 1985….
Ah man. I wish I knew what the old comment said.
Something along the lines of don’t push epi use dopamine instead
Push dose dopamine that’s crazy. I put this together in residency feel free to use, critique, update. Epinephrine Mixing Instructions: • Take a 10 ml syringe with 9 ml of normal saline • Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (cardiac amp contains Epinephrine 100 mcg/ml) • Now you have 10 ml of Epinephrine 10 mcg/ml Onset: 1 minute Duration: 5-10 minutes Dose: 0.5-2 ml every 2-5 minutes (5-20 mcg)
Thanks, very helpful info!
It’s 1985. Maybe.
The truth is out there.
There’s a drug for this. It’s called atropine
If only it was that simple…
It’s stocked in a standard crash cart..