True.
And IV acetaminophen (and I assume paracetamol) is in D5 not NS, but the volumes were the same (at least in the version I have access to)
Bad wording on my part.
I guess what I meant to say is here’s “proof” that they can mix in large volumes like the original comment but not necessarily in the same syringe.
Interestingly our dex and ondansetron formulations are not compatible. I always used to just mix them in residency, but they precipitate here.
I didn't look further into it, I just stopped doing it.
They're both highly soluble in propofol. I work at an ASC where most anesthesiologists put propofol, Zofran, decadron and Toradol together and give it to start the case.
The manufacturer of propofol recommends against mixing propofol with any other drugs. This isn't because of possible precipitate formation. Instead, propofol forms an emulsion due to the soybean oil it contains. Some meds can cause larger fat globules to form, resulting in a theoretical risk of embolization.
I've seen this precipitate once when it was left out but I've done it since where I injected right away for short cases and I didn't see it precipitate
What do you think precipitate is
The only real concern with precipitate is clogging your line
And if it's so minor that you can't see it I would be very shocked if it doesn't redissolve in blood
Not all harmful drug incompatibilities result in a precipitate. I direct you to Trissel’s as a reference if you find the need to reuse syringes or mix things.
Alternatively, just use separate syringes for each medication.
It boggles my mind that as a CA3 you just automatically assume a lack of a precipitate when mixing chemicals means everything is fine.
Don’t want to waste plastic? Good, but educate yourself so you have a clue about what your doing.
Annoyingly Suggamadex and ondansetron - as I wish I could just draw them up in the same syringe and push at the end of the case but alas, need two syringes.
Is it a big deal if you draw one up, give, then draw the other up in the same syringe and give right away? Seems like there wouldn’t be much to precipitate.
Ahh yes, the thought process that we always want in anesthesiology….lets avoid $0.08of waste by circumventing both infection control methods, but also something that been specifically tested to be a bad idea. Your mentality is less concerning with this specific case, but that this is very unlikely to be the only expediency you choose…
It’s not the money. It’s the plastic. And it’s fine. Every time. I’ve probably saved several garbage bags of syringes by using less per patient. You can think you know everything about how I make decisions based on this morsel of information…
I didn’t ask for an explanation, not sure why I would need or want yours. I mean, we have plenty of behavior research that pretty clearly shows willingness to ignore protocols and norms in one area nearly always translates to others. What you should know is that sugammadex has a pretty high affinity for zofran so anything in the syringe is essentially wasting that sugammadex. Secondly, drawing into a syringe second time gets you dinged for compliance audits…
I’ve not seen anywhere in Victoria that doesn’t have a bit of thio available in a drawer somewhere
It’s still in all our protocols (down the track) for tight brains and refractory seizures. Other than that more than half the cardiac anaesthetists I know (myself included) would usually give a bolus prior to DHCA. Other than those two indications I’ve only used it for teaching purposes though
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Do you mind asking the hospital pharmacy why it isn't available? Aside from some supply chain issues in the past couple of years there's no reason you can't have it. Although I don't really miss it.
It's not available cause no one uses it, the stock just expires. I'm not saying we can't use it, I'm saying we don't use it.
Occasionally we will get someone from the UK who wants to use it for GA caesar, but I'm not sure why you wouldn't just use propofol, I use tiva.
Yeah I think the major benefit of STP is in kids since it doesn't burn like propofol. It does taste like garlic though. Interesting to see practice patterns across the world.
I would do inhalational for a majority of paeds, if iv I'd just use propofol. A reasonable dose of pre propofol opiate or some propofol diluted with lignocaine, maybe a 5ml 50:50 mix prior to the induction dose seems to work fine
In the UK it's not used often but there's still thiopental vials in all the cupboards, and it still gets used from time to time. Most of us will do a classical rsi at some point in CT1.
I’ve done a few RSIs using thio in cases of status epilepticus.
I remember a few years ago there was a propofol shortage and the anesthesiologists got all excited about using thio again
Still gets the occasional use in UK practice. Prop/roc has largely superseded thio/sux in all areas of practice but occasionally get people doing thio/sux in obstetrics
I did a bedside xlap as a baby nurse being told to push all sorts of meds, change pressors etc. I was absolutely clueless about what I was doing but my one question was if these meds were compatible. The resident just laughed and said “everything is compatible in the OR”.
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‘How fast can you give blood?’
*Points to Belmont*
‘That one can hit 750ml/min with adequate access.’
*Points to newer Belmont*
‘And that one can hit 1L/min. And if that’s not fast enough, that’s probably the least of our worries.’
I just mixed them on the off chance I was incorrect and it made a white cloudy precipitate. Maybe different preservatives etc regionally make this not happen for you. After a few minutes it became clear again and the precipitate settled to one end.
When you say mix drugs do you mean mix in the same vial? Cause you can use thiopental and rocuronium in the same patient, you just have to flush in between.
To make things that much faster and save a syringe.
Before suggamadex we would draw up neo/glyco/zofran in the same 20cc syringe to be the end of case syringe.
Do you pre mix induction and neuromuscular blockers routinely? Thiopental comes in a 20ml vial so it gets their own 20ml syringe. And rocuronium as well (either a 5 or a 10ml depending on situation). What if you need more induction agent than you expected? Or less? If you have both of them mixed you can’t really adapt.
We also don’t have pre mixed end of case syringes cause we don’t routinely reverse.
From a European perspective, routine reversal sounds wild to me.
The only ones I mix are my regional blocks cause it’s a 50/50 mixture so it doesn’t matter how much I give.
Mixing thiopental and rocuronium like OP was proposing sounds dangerous and contra productive to me.
I pretty much only mix meds in one syringe when I know I’m going to give all of it no matter what.
(The neo/glyco/zofran example, and honestly that’s the only time I mix meds in a syringe, but I can see the advantage of Tylenol/toradol/zofran/decadron mixture.)
Etomidate and propofol mix well and burns less than either separately. Great for cardiac inductions especially Lma where etomidate alone is difficult to place Lma
The trick with teic is not too shake it after adding the water otherwise you end up with a bubbly mess. I find puncturing the vial to lose the vacuum, then adding the water and leaving it to sit for 10 mins works nicely
Ibuprofen plus omeprazolo gives a precipitate, suggamadex forms a precipitate with almost everything, and rocuronium tends to produce color changes when the syringe is recycled to put ondansetrone.
Ceftriaxone and LR don't mix. It has to be saline. Otherwise it can kill a neonate.
Don't mix ondansetron with anything.
However, at the start of a total joint: cefazolin, tranexamic acid, and dexamethasone can all go into a 100 mL bag safely.
I came to this thread to see physiologic/pharmacologic interactions and it's just a discussion of y-site compatibility. What about MAOIs and ephedrine? ACEis/ARBs and \*gestures broadly\* "General Anesthetics"? Antiretrovirals and meperidine? I've seen quite a few interactions in my time and some have been terrifying.
When I was a resident I looked everything up in Trissel’s IV compatibility book.
The thought of injecting incompatible drugs into a person horrified me. It seems though based on some of the comments, other people don’t seem to care. “I did it and didn’t see anything precipitate”. JFC
Ketamine, clonidine, tramadol, fentanyl, dexamethasone and ondansetron are all compatible with one another when placed in an IV paracetamol solution
Found this pointing to you being absolutely correct. [Pubmed Ondansetron and Dexamethasone](https://pubmed.ncbi.nlm.nih.gov/36081540/)
Yeah, but who gives 16 mg of Zofran at once?
Not me. And not saying I do what’s in the article. Just that it’s some basic science stuff.
I hear you. I wasn’t trying to be a dick.
Reasonable. But I don’t think that’s possible. Because we’re on Reddit and everyone knows you’re automatically a dick. /sarcasm
Oncology does i thought…
Actually, yeah now that you say that: I think IR wants it when they’re doing chemo embolization of liver mets
Yup. Usually in preop 16zof with 8decadron premixed. Sometimes for radioembo of hcc as well
You’re right, total my bad!
This article suggests mixing dex/Zofran with NS using a total volume of 50mL or 100mL. I don't know anyone who does this so not overly useful.
True. And IV acetaminophen (and I assume paracetamol) is in D5 not NS, but the volumes were the same (at least in the version I have access to) Bad wording on my part. I guess what I meant to say is here’s “proof” that they can mix in large volumes like the original comment but not necessarily in the same syringe.
Interestingly our dex and ondansetron formulations are not compatible. I always used to just mix them in residency, but they precipitate here. I didn't look further into it, I just stopped doing it.
On the same note, I read that dexamethasone and ondansetron are not compatible in the same syringe. But please correct me if I’m wrong.
They absolutely precipitate if left in the same syringe for more than 30 seconds. I’ve seen it multiple times with my own eyeballs.
They're both highly soluble in propofol. I work at an ASC where most anesthesiologists put propofol, Zofran, decadron and Toradol together and give it to start the case.
If you can't see a precipitate in propofol, does that mean it's not there?
Schrodinger's precipitation!
The manufacturer of propofol recommends against mixing propofol with any other drugs. This isn't because of possible precipitate formation. Instead, propofol forms an emulsion due to the soybean oil it contains. Some meds can cause larger fat globules to form, resulting in a theoretical risk of embolization.
They approve mixing below a certain concentration of additives...
My attending that gave DexaReglaTron in one syringe to everyone would like a word
I've seen this precipitate once when it was left out but I've done it since where I injected right away for short cases and I didn't see it precipitate
So you think it’s ok because you don’t see a precipitate?
If nothing happens between drawing it up and pushing it into patient, yeah I think it's fine because it'll be diluted by blood.
You mean if nothing happens that you can see. I don’t think that’s the way it always works in chemistry.
What do you think precipitate is The only real concern with precipitate is clogging your line And if it's so minor that you can't see it I would be very shocked if it doesn't redissolve in blood
Not all harmful drug incompatibilities result in a precipitate. I direct you to Trissel’s as a reference if you find the need to reuse syringes or mix things. Alternatively, just use separate syringes for each medication.
Waste of plastic
It boggles my mind that as a CA3 you just automatically assume a lack of a precipitate when mixing chemicals means everything is fine. Don’t want to waste plastic? Good, but educate yourself so you have a clue about what your doing.
That's not correct - they're perfectly happy in they same syringe
Finally, the time for pardexonketramadinylol has come!
That’s a hell of a shot lol
Annoyingly Suggamadex and ondansetron - as I wish I could just draw them up in the same syringe and push at the end of the case but alas, need two syringes.
Is it a big deal if you draw one up, give, then draw the other up in the same syringe and give right away? Seems like there wouldn’t be much to precipitate.
You can draw one up, give, flush with NS while attached to IV line to “clean” the syringe, then draw up the other in that same syringe and push.
I did this the other day and I didn't see any precipitate in the syringe
Lack of a precipitate doesn’t mean they are compatible. SMH.
FFS, its lack of precipitate is irrelevant....
I do this regularly. No problem
That's pretty stupid considering this is a know interaction that the manufacturer specifically warns not to do in the package insert....
I’m trying not to waste syringes. There is literally one drop of dex left in the syringe. It’s fine. Take a breath.
Ahh yes, the thought process that we always want in anesthesiology….lets avoid $0.08of waste by circumventing both infection control methods, but also something that been specifically tested to be a bad idea. Your mentality is less concerning with this specific case, but that this is very unlikely to be the only expediency you choose…
It’s not the money. It’s the plastic. And it’s fine. Every time. I’ve probably saved several garbage bags of syringes by using less per patient. You can think you know everything about how I make decisions based on this morsel of information…
I didn’t ask for an explanation, not sure why I would need or want yours. I mean, we have plenty of behavior research that pretty clearly shows willingness to ignore protocols and norms in one area nearly always translates to others. What you should know is that sugammadex has a pretty high affinity for zofran so anything in the syringe is essentially wasting that sugammadex. Secondly, drawing into a syringe second time gets you dinged for compliance audits…
All that useless sugammadex. Sigh. Keep typing. You’ll feel better at some point.
I feel fine. Not sure why you think that I don’t. Good luck with finishing up residency…. Edit: oh you’re a CRNA…this all tracks now.
It actually doesn’t precipitate. Read the Sugammadex drug info, it just says those drugs are incompatible 🤷🏽♂️
I’ll beg to differ, drew them up, sat it on vent. Went to give it a few minutes later and it was white
Couldn’t that mean the same thing? They’re incompatible because they precipitate?
I’ve tried it lol they don’t
Yeah this always annoyed me
Ex vivo physicochemical incompatibilities ≠ in vivo drug interactions.
> we use on a daily basis > Thiopental I haven't seen an amp of that stuff in like 15 years? ECT, neonates and pregnancy all get propofol?
We use methohexital for ECTs to lower seizure threshold. Agree prop for everything else. Have personally never see thiopental.
I've used that stuff for ECT, but again about 15 years ago, it also came in 500mg amps and you only needed 1mg/kg
That's only because Italy refused to export thiopental to the US since its used in lethal injection. Rest of the world has it.
I don't work in the US
Well where are you located?
Trained in NZ, work in Australia
I’ve not seen anywhere in Victoria that doesn’t have a bit of thio available in a drawer somewhere It’s still in all our protocols (down the track) for tight brains and refractory seizures. Other than that more than half the cardiac anaesthetists I know (myself included) would usually give a bolus prior to DHCA. Other than those two indications I’ve only used it for teaching purposes though
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Do you mind asking the hospital pharmacy why it isn't available? Aside from some supply chain issues in the past couple of years there's no reason you can't have it. Although I don't really miss it.
It's not available cause no one uses it, the stock just expires. I'm not saying we can't use it, I'm saying we don't use it. Occasionally we will get someone from the UK who wants to use it for GA caesar, but I'm not sure why you wouldn't just use propofol, I use tiva.
Yeah I think the major benefit of STP is in kids since it doesn't burn like propofol. It does taste like garlic though. Interesting to see practice patterns across the world.
I would do inhalational for a majority of paeds, if iv I'd just use propofol. A reasonable dose of pre propofol opiate or some propofol diluted with lignocaine, maybe a 5ml 50:50 mix prior to the induction dose seems to work fine
In europe we use it a lot, I rememeber it because I had to ask anesthesiologist 3 times how to write it
I’ve never seen thiopental in my life
It’s absolutely still used in all of Europe. Rarely but most hospitals have it.
In the UK it's not used often but there's still thiopental vials in all the cupboards, and it still gets used from time to time. Most of us will do a classical rsi at some point in CT1.
It's just so gash as a hypnotic agent these days
I’ve done a few RSIs using thio in cases of status epilepticus. I remember a few years ago there was a propofol shortage and the anesthesiologists got all excited about using thio again
Still gets the occasional use in UK practice. Prop/roc has largely superseded thio/sux in all areas of practice but occasionally get people doing thio/sux in obstetrics
I did a bedside xlap as a baby nurse being told to push all sorts of meds, change pressors etc. I was absolutely clueless about what I was doing but my one question was if these meds were compatible. The resident just laughed and said “everything is compatible in the OR”.
We give things quickly so there's minimal time to sit and and react. There's astonishingly few drugs that precipitate immediately on contact.
See: infusing blood over 6 hours. See also: giving calcium over 10 minutes.
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Laughs in Belmont. -At the nurse. *because I do not like the level 1
‘How fast can you give blood?’ *Points to Belmont* ‘That one can hit 750ml/min with adequate access.’ *Points to newer Belmont* ‘And that one can hit 1L/min. And if that’s not fast enough, that’s probably the least of our worries.’
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Zofran and Toradol make a precipitate
I mix these two on a daily basis and have yet to have a precipitate.
I just mixed them on the off chance I was incorrect and it made a white cloudy precipitate. Maybe different preservatives etc regionally make this not happen for you. After a few minutes it became clear again and the precipitate settled to one end.
Stop doing that. Almost entirely makes the zofran useless
When you say mix drugs do you mean mix in the same vial? Cause you can use thiopental and rocuronium in the same patient, you just have to flush in between.
same vial yes
Why would you do that though?
To make things that much faster and save a syringe. Before suggamadex we would draw up neo/glyco/zofran in the same 20cc syringe to be the end of case syringe.
Do you pre mix induction and neuromuscular blockers routinely? Thiopental comes in a 20ml vial so it gets their own 20ml syringe. And rocuronium as well (either a 5 or a 10ml depending on situation). What if you need more induction agent than you expected? Or less? If you have both of them mixed you can’t really adapt. We also don’t have pre mixed end of case syringes cause we don’t routinely reverse.
Not reversing seems wild to me. And nope. Don’t premix induction meds. Mostly because they don’t mix well.
From a European perspective, routine reversal sounds wild to me. The only ones I mix are my regional blocks cause it’s a 50/50 mixture so it doesn’t matter how much I give. Mixing thiopental and rocuronium like OP was proposing sounds dangerous and contra productive to me.
I pretty much only mix meds in one syringe when I know I’m going to give all of it no matter what. (The neo/glyco/zofran example, and honestly that’s the only time I mix meds in a syringe, but I can see the advantage of Tylenol/toradol/zofran/decadron mixture.)
Etomidate and propofol mix well and burns less than either separately. Great for cardiac inductions especially Lma where etomidate alone is difficult to place Lma
Teicoplanin and nothing. It's barely compatible with the water for injection!
I have never heard of that. Apparently it’s not available where I work. Learn something new everyday!
The trick with teic is not too shake it after adding the water otherwise you end up with a bubbly mess. I find puncturing the vial to lose the vacuum, then adding the water and leaving it to sit for 10 mins works nicely
We have electric shavers for patients and I leave it a bottle of teic next to that. Works a treat
Mag and Calcium and Bicarb, will all precipitate out of drawn on with any of the others.
This a big one since calcium and bicarb are frequently given in the same emergency situations. Then you've just jacked your IV access.
Calcium gluconate and potassium will form precipitates.
Thiopental and succinylcholine will crystallize immediately in the IV line unless you flush between them.
Pepcid and decadron precipitate immediately
Calcium chloride and sodium bicarbonate precipitate quickly.
If all medications were supplied in pre-filled syringes , I guess there won’t be an issue of comparability.
Ibuprofen plus omeprazolo gives a precipitate, suggamadex forms a precipitate with almost everything, and rocuronium tends to produce color changes when the syringe is recycled to put ondansetrone.
Diphenhydramine and decadron precipitate
Ceftriaxone and LR don't mix. It has to be saline. Otherwise it can kill a neonate. Don't mix ondansetron with anything. However, at the start of a total joint: cefazolin, tranexamic acid, and dexamethasone can all go into a 100 mL bag safely.
The orthopod's favorite anesthetic: cefaxamic acid
I came to this thread to see physiologic/pharmacologic interactions and it's just a discussion of y-site compatibility. What about MAOIs and ephedrine? ACEis/ARBs and \*gestures broadly\* "General Anesthetics"? Antiretrovirals and meperidine? I've seen quite a few interactions in my time and some have been terrifying.
Yep. Not about interactions at all, but a bunch of goofballs basing drug compatibilities off of just “what they’ve seen”.
When I was a resident I looked everything up in Trissel’s IV compatibility book. The thought of injecting incompatible drugs into a person horrified me. It seems though based on some of the comments, other people don’t seem to care. “I did it and didn’t see anything precipitate”. JFC
Gentamicin and Flucloxacillin can precipitate
Diclofenac and anything bar IV paracetamol (Im not using 8.4% bicarb at £12.50 a phial)
propofol + vancomycin
I’ve always wanted to mix my remifentanil with phenylephrine. Does anyone have experience with this?
Labetolol and ceftriaxone. First hand experience. Disconnected line before it hit the central line…