So a recent paper reopened my hate on “dirty epi.” I use my buddy, Reub Strayer, as the stand-in for the dirty epi lovers as he coined the term on his EM Updates Blog post.
The Recent Study
Braham D, Adams DWS et al. Pre-hospital ‘dirty adrenaline’: A descriptive case series of patients receiving peripheral dilute adrenaline infusions in Central Australian remote nurse-led clinics prior to aeromedical retrieval [10.1111/1742-6723.14496]
Problems with Dirty Epi
- Unrestrained
- Unmeasured
- Dilute
The study did not look at Dirty Epi, it looked at mildly-messy epi!
Mildly Messy Epi Drip
Mix the epi 1 mg (either 10 ml or 1 ml form) into 1000 ml bag of fluid (usually NS). Then put it on a PUMP!
Set the pump's ml/hr to 60 x your desired mcg/min rate (so 5 mcg/min x 60 = 300 ml/hr)
Set Volume to Be Infused (VTBI) to 1000 mls and you are good to go.
The Paper's Authors' responses to my request for more info
Hi Scott,
Many thanks for your kind words and it's a pleasure to chat with you. Dave has done a fantastic job leading this review and I am very excited to see some data from our corner of the world hit the internet.
My comments on your questions:
Re 1) Infusion pumps are widely available in the remote area clinics in our catchment so drip count is only a backup (and rarely used). I have never had to fall back to it on a case myself. We didn't specifically collect pump vs free, and there is only one case with a free-flowing infusion clearly documented. For this n=1 subgroup:
- Age 84. Indication was septic shock
- They were in our “outer rim” so the clinic RAN was on their own with them for a number of hours
- They went from 1mcg/ml to 3mcg/ml, reasoning not documented but with known renal disease I presume the consultant was limiting volume.
- No complications of therapy, received 1.5L fluid in clinic.
- BP 60/38 at time of commencement and 105/50 when we arrived
- We switched them to norad for the transfer.
- Survived to discharge after a 2 day ICU stay and a 6 day hospital stay. Nice work team.
I take your point about the definition of a “dirty epi” drip being free-flowing, but we have always referred to dilute adrenaline on a pump as dirty adrenaline around here.
Re 2) I don't think any doctors in our service are worried about what cannula is used as long as the line is clearly patent. The development of the protocol provided did require compromises to appease all parties. I’d hoped to demonstrate with this review that line site and size don’t matter, and I am happy we've done so.
One practical reality is that the primary care nurses doing this are often really stressed with these patients. There is lots to do and do quickly, and at best there will be 2 of them in the clinic. Their day-to-day work is not crit care. This is usually not a 9-5 scenario so they are tired. In some cases it is the first time they've ever given adrenaline! In my opinion, all this makes the outcomes for this group of patients genuinely noteworthy.
Kind regards,
Daniel Adams
Director | Central Australian Retrieval Service
Director | Central Australian Retrieval Service
Hi Scott
Firstly, it is a genuine honour for you to be interested in my paper. It’s my first ever publication and I’m thrilled with the level of interest it has gained.
1) Infusion pumps are used in most cases, however in some remote clinics where an infusion pump is not available the nurses are encouraged to manually calculate drip rate to ensure an accurate infusion rate.
2) The protocol was written before my time with the service, however I think the instructions of using a wide bore cannula in the ACF is based on best-guess and the potential evidence from the Loubani et al systematic review on peripheral vasopressors in 2015 which suggests adverse events appear to be associated with distal sites. Ultimately these are sick people in the middle of nowhere though, and the level of experience amongst the remote nurses is hugely varied. So any cannula they could get in is better than none, and it seems that no significant adverse events came from the smaller-bore and more distal cannulae. Keeping the current guideline regarding this is probably fair for best-practice purposes until further evidence that distal lines and small bore cannulae are / aren’t as safe as proximal large bore cannulae.
Thanks very much again, happy to answer any further questions as best I can.
David Brahm
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An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hi!
from my austrian anesthesia and EMS point of view all i really do for peripheral pressors (or inotropes) is norepinephrin (or epinephrin) 1mg/50ml in a pump (syringe driver).
low conentration and high flow = safe dose.
i think this method counters the problem of unsure dosage and the safety regarding extravasation.
very few EDs or ICUs have syringe drivers, they are almost exclusively in the ORs and Pediatric Units
Hi Scott, I think this appears to be a sliding scale of speed/urgency weighed against elegance/safety. We have guidelines from the Intensive Care Society in the UK around peripheral adrenaline (4mg in 250mL of 5% glucose) for an 8mcg/mL mix which I usually have time to do. The time taken is usually the time to prime the giving set through the pump (getting rid of air bubbles ). As far as I can see, setting up the mildly messy epi would take about the same amount of time as doing a proper job with a peripheral adrenaline infusion so the… Read more »
not sure which argument you are responding to, Dean
My apologies – essentially, my point is if you’re going to do the ‘mildly messy’ epi drip, you might as well do it properly and draw up the peripheral epi pressor drip (4mg in 250mL) as it takes the same amount of time and only difference is volume/concentration of the drug.
Hey Brother, Not sure if you were responding to the podcast or just the show notes. I had mentioned the reasons why people thought this was a good idea:\ you are in a non-hospital setting where they do not keep epi a lot of epi on hand, do not have drips sheets or preprogrammed pumps–hence the advantage of justt needing 1 mg and being able to figure out drip rates on the fly. An icu that doesn’t stock meds other than code cart and feels the need for an epi drip prior to pharmacy sending once up after ordering. For… Read more »
I.m also a push dose pressor guy and agree completely on everything you said about the dirty v/s messy drip, except for 1 thing: You mention in the podcast that the more diluted form will be some how safer if the IV moves and it extravasate.… I think this is not a real thing and there is not a safety advantage (from the extravasation stand point, in regards of the infused dose for F*** sake use a friggin pump) here is why: In the first place epi es not going to cause any real issue at any of those concentrations!!… Read more »
in principle, I agree with all of your points. Here is the thing: extrav. injury is Volume x Concentration you are generally going to be safe even with the ultra-concentrated anaphylaxis dose of epi, it is 0.5 ml regardless of the concentration the concentration of push dose is 1:100,000 (i know we are not supposed to speak about it in this form anymore, but I am doing it b/c we know this is identical to what we use in lidocaine with epi) Obviously the dilution of dirty epi is even less prone to injury, As you get more concentrated, the… Read more »
Thanks for answering. Same coin different perspective I think. on a related issue: If I understand your practice you usuale take 1ml from cardiac epi, diluted it with saline in a 10cc syringe so you have a 10mcg/ml and use that for push dose,. We don’t have “Cardiac Epi” (the 100mcg/ml) only the 1mg/ml,, si what I do when I have time (almost never), and I think i might want my push ready in addition to the norepi drip (or rarely I need pressors have time and cańt have the norepi pump ready for X reason) is put the 1mg… Read more »
yes, that makes sense! In your situation, my solution would be to have pharmacy make the push dose epi under the hood. It would take them a few minutes to make 10 sterile syringes that can last 72hrs to up to a week.