Way back in episode 6, I laid out instructions for and denoted the uses of Push-Dose Pressors [PDP]. The PDP I loved most was push dose epinephrine! The mixing instructions I put there have served many departments in good stead for the past 14 years. Then friend to the show, Sam Ghali, approached me with the way he has started mixing up Push Dose Epinephrine. In this wee, I lay out that method and discuss the pros and cons. What I would really like though is for you to weigh in using the comments section below…
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EMCrit Podcast 205 – Push-Dose Pressors Update
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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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Seems much simpler to teach and implement. In the prehospital system where I’m working, we’re about to do our first training on push-dose epinephrine and make PDP part of protocol. Currently, I use the labels from podcast episode 176 and another nice thing about simply drawing up 1ml is the label would no longer require the mixing instructions. Training would be much simpler as well. 2 questions I can think of about this are: How realistic is it to administer 0.1-0.2ml slow enough for PDP (my understanding was 10-20mcg over a minute or two- is that correct)? Is there any… Read more »
I like the idea. A three-way stopcock can alleviate a few problems: 1) The plunger of a 1 mL syringe can easily be depressed by accident when it is not attached to anything, so you can “lock” it off. 2) We cannot get luer-lock 1mL syringes right now, with the stop cock you don’t have to fight the rubber stop on the injection port. 3) You can attach a flush and push the small volume through if the line does not have fluids running through it since you are giving less than the priming volume of most extension sets. I… Read more »
That is a great idea! The only problem is that having the stopcock the wrong way by accident might lead to “badness”.
One thought why not just draw up a single dose from the code epi and give it then only draw up more if needed? If the drip is ready at all quickly should only need one dose a lot of the time. The way I do this in the prehospital environment is actually different and is very fast, I mix 1mg/1ml in 100 ml bag then give 1-2 mls push. Then very easy to spike and start drip. Non standard concentration but we programmed it into our pumps. I’m just possessive over it until the hospital can get their stuff… Read more »
I think simplifying the process would make some people less nervous. Everywhere I’ve worked it’s always phenylephrine we’re pushing and from my conversations with our Icu fellows it seems they prefer neo mostly because it comes in a premixed syringe so there is less chance of med error. This is especially true when the docs are asking nurses to give the meds for them which is the case in many units. Is there a reason pharmaceutical companies can’t sell premixed push dose epi? Also many hospitals don’t stock 1 ml luer lock syringes so we would need to start ordering… Read more »
Mordechai, there are companies that manufacture pre-mixed push-dose epi sticks. We carry pre-mixed phenyl sticks and pre-mixed epi sticks in our RSI kits. The PDP epi pre-mixed sticks have been tough to get lately as has basically every other medication with shortages but they are out there. Google actually has a picture linked to emcrit episode 205 in the image search, I don’t remember the name of the pharmaceutical company but that picture is the pre-mixed stick we carry.
Very cool I’ll have to bring this up with our department.
Thanks
Can you by chance take a photo of the one you carry? And/or tell us the manufacturer on the label? I’m trying to find where to get pre mix epi PDP sticks. The Google photos say PharMEDium which was bought out and closed down in the past few years.
We use epi and neo as push dose and infusion pressors. Our epinephrine PDP kits consist of : 100 ml bag of normal saline, epinephrine 1 mg/ml and a 10 ml syringe. Our final concentration is 10 mcg/ml and by drawing 10 ml from the mixed bag I’ve got several push doses ready to go as a “boom stick”. I routinely ready a syringe of PDP epinephrine when I’m drawing meds for a medication facilitated intubation.
exactly what we‘ve been doing all along and in my opinion the best way. In my experience 1ml syringes are kind of too frickle, dosing errors happen rather easy (everyone who administers insulin knows what a pain it can be to be precise with those).
Here in Italy pre-filled syringes with epi are pretty much a rarity, what we usually have are 1mg/mL ampoules and that’s it.
So the usual routine is to take that vial, put it in a 100 mL NS bag, tape it in red, and then I have the usual 10mcg/mL dose I can administer with whatever syringe I have on hand (usually a 10 mL one for easily repeatable doses).
I like the no mixing prob the best and from what I remember you saying previously was to not squirt one cc from a prefilled syringe but to draw up 9 cc of NS in a fresh syringe and then 1 cc of the cardiac epi as the flushes were not designed to be for more exact admission of medicine- but I could be misremembering- regardless Sam’s 1 cc syringe is great- I’m ordering some green ones today!
I really like using the 1mL syringes and love the idea of using a colour-coded syringe. There is a precedent for this in pediatric cardiac arrest… we will use a 3 way stop cock to fill the 1mL syringe from the pre-filled “code-epi” syringe.
I like the idea of not needing to do math. My two critiques with this are as follows: The small volume of 0.1 mL is not enough to make it through the lurelock hub of most IV tubing. The priming volume for one of the hubs I use is 0.08 mL. Therefore, it is very important to ensure you disconnect the syrine and flush it through from the same hub even if an IV line is flowing. With regard to labeling, I would advocate using a purple label or syringe since that color has been standardized in the anesthesia world… Read more »
Great points
I like the idea of removing the mixing requirement from push-dose vasopressors. I do have a human-factors concern with this approach if rolled out to the broader community. Having a mixing requirement paints a nice line in the sand that administration of pure cardiac epinephrine is not safe. I fear that switching to administering pure cardiac epinephrine without the dilution requirement will bring some to question the need to draw into a different syringe at all. “If I’m giving the same solution, why can’t I just push from the original syringe? It’s cleaner, and I’ll be careful. It’ll be fine.”… Read more »
I love the idea. You cannot forget to make sure the epinephrine gets flushed adequately into the patient. With the extremely small volume, there is significant flush volume needed to get to the patient.
Great stuff.
The neonatalogists were drawing 1ml of 1mg/10mL prefilled epi into a 1mL syringe and titraring when I got recertified at the NRP.
Also, we did some in situ pediatric simulations at my new place and the nurses were all doing it naturally to draw the right amount of epi to give during a pediatric arrest.
When I saw that, I just thought we should do this for push-dose adrenalin in adults!
Also thought “Why did I never see that before?” Such a simple and elegant way of doing it.
I like to mix 1mg/1ml epinephrine to 100ml 0.9% NaCl.
you can do norepinephrin or epinephrine, the term we use at the place where i work is “Nor-Blitz” or for epinephrine “Supra-Blitz” – the brandname for epi is Suprarenin here.
it is easy to mix and you have no problem to draw up further doses + syringes with lightningbolts plus a sticker (nor or epi) indicates for all the personel whats in there, even if its drawn up quick.
and dosing 1ml out of 10mls is quite doable. 🙂
I see the beauty in the simplicity of this, but I’m worried that if you push 0.1 mL into a lier lock hub, a significant amount of your dose will remain in the dead space volume of that hub.
Mixing 1mg of 1:1000 in 100 ml bag is as simple as it gets. Then you draw up 10 ml in a 10ml syringe. Its accurate and the medication is diluted enough to push without necessarily needing a flush. Pushing 0.1 – 0.2 ml would need to be flushed.
I agree- being nit picky- as long as you know it’s 9.1mcg and not 10 (1000/110). 10 is only out of convenience anyway and it’s the clinical outcome we’re concerned about and if you get there with 9.1 or 13.6 etc isn’t really relevant. Just know what you’re doing, what you’re giving and monitoring the outcome you want. That’s more important than a 0.9mcg difference
Hello! I’m a EM resident from Italy. Unfortunately we do not store pre-made 100 mg/ml Epi syringes and the use of PDP is rare outside of ORs. I think that for my practice pushing 1 mg into 100 mls, mixing, and then drawing 10cc syringes + syringe kept a part of the other ones (i.e. In my pocket) + idiot-proof label is still the simplest and safest way to use PDP.
Lorenzo Fornaciari
I’m concerned that using a 1ml syringe could lead to accidental administration of the full ammount more often. Using a 10ml syringe, properly labeled, can act as a barrier to accidentally instilling the full amount. When preparing and administering RSI drugs, I use a 20ml for sedation/induction and 10ml for the paralytic as a memory tool for which is which. This frees up some mental bandwidth.
Our institution has been moving away from push dose epi generally, preferring phenylepherine, which is also prepared in a 10ml syringe.
From my anesthesia world, I inject 1mg epi vial into 100ml bag of saline. Label bag appropriately. Alternatively, inject the 10ml epi code syringe into 100 ml bag. The concentration will be slightly less. Finally, the easiest solution is to grab a premix back of epinephrine (usually 8mcg/ml or maybe 16) and draw a 10 ml syringe from there. You can do the same with norepinephrine. 16mcg push of norepinephrine with give you a nice BP kick,
Has Lidocaine 1% w/ Epi ever been considered? It would have the 1:100,000 desired epi concentration (10ug/mL) and only Lido 10mg/mL. Although Lido has hypotension listed as a side effect, has this been experienced with such a small dose? This would eliminate the mixing and labeling issues. There would be limitations in smaller weght patients and repeat doses. In the pre-Amiodarone days, I do not recall hypotension being common with the initial 1 mg/kg bolus.
I am just a little bit worried that sometimes FOAMed is balancing between evidence based medicine and practice based medicine. And such big names as Scott has a huge impact on the whole EM society especially in the developing ones. Where junior doctors don`t have local “starts” to look up to. And often when I ask junior doctors why are you doing this or that, they are saying that I am doing this because Weingart is doing this. What I mean is that, with all the respect to Your knowledge and skills, to everything you are doing, and the safety… Read more »
Definitely an easier method, but be aware the NS flush syringes are only intended to push out, since the barrel isn’t sterile. They are not intended for mixing meds. Also they must be labeled. We use commercial prefilled syringes for Anesthesia and Critical Care use. Not cheap, but sterile & labeled.
Hi Scott. I think this absolutely could work. My focus is on your discussion of the transition costs. This is clearly worth it if the change is for the better. In this situation, I’m not convinced that it’s an improvement. I think it’s as good, but not better. Because it’s not an improvement, I don’t see that there’s a benefit to justify the transition costs unless you don’t have 10 cc flushes available.
Overall, I like the simplification of a one syringe system that seems to eliminate med errors associated with concentration changes. My only concern is if at such low volumes, there is a clinically significant volume loss which has been described in some literature associated with closed circuit. transfer devices like lure locks. Admittedly, I haven’t read the full version of these articles but in the abstracts it seems that 0.1 ML‘s is the going rate of volume loss with Luer lock adapters. What are your thoughts?
https://ysprogram.ucdavis.edu/content/measuring-and-predicting-syringe-hub-loss
https://journals.sagepub.com/doi/abs/10.1177/1078155219888682?journalCode=oppa
Hi Scott. Love the show. I work as a flight nurse for a hospital based program. Our standard way of making push dose epi is to mix 1mg of the 1mg/1ml epi in a 100ml bag creating a 10mcg/ml bag of epi. We then use a medication spike with a luer lock on it to spike the bag so that we can draw up as much as we need. I usually use a 10ml syringe but you could easily use a smaller syringe and draw up the dosing you need. I use a carabiner to clip the bag to my… Read more »
Didn’t see your comment before I commented, Brian. This is the method I think is safest and simplest.
I have always avoided the code epi syringes entirely. At all the hospitals I’ve worked at, we have had anaphylaxis kits at the ready that contain the 1mg/ml epi vials. I add one of these to a 100ml NS bag to get the 10mcg/ml push dose concentration. I draw up a 10ml syringe from that bag and discard the rest (well okay I actually put it in my pocket but it is out of the way). This lets me not have partial code syringes lying around, it lets me avoid needing any luer-lock to luer-lock connectors or (gasp!) 3way stopcocks… Read more »
Hey Scott,
Sam mentioned that he had difficulty with the original push dose because his ED only stocked 5ml prefilled saline flushes.
The simple solution for that would seem to be 1ml of “cardiac epi” (100 mcg) in 4 mls of saline for 20 mcg/ml. Even if that extravasates that shouldn’t cause tissue damage and 20 mcgs is a completely fine dose of IV epi, right?
Interesting concept. I moved away from anything in 1cc syringes after too many plungers got accidentally knocked off the end, resulting in all the medication on the floor. Too risky for me with narcotics and appearing to have accidental waste. Not as a big a deal if epi ends up on the floor, but likely frustrating with a critical patient.
I personally feel that the 1 ml in a 10 ml syringe is the easiest way because we already use the same steps in converting 1:1000 epi to 1:10000 epi which makes it easier to learn and I feel as long as you remember to label it, it’s still the safest and less likely to screw it up. Also while yes you probably will cause harm if you push the whole thing by accident I think there’s more danger in trying to add complications to drawing it up in the first place
First off, I absolutely love this idea however, my only issue with this is that the 1ml syringes have a tendency to be less structurally integral than 3ml, 5ml, 10ml syringes. In my brief, five years in emergency medicine is the only syringe I’ve ever seen fail, and usually it’s due to the plunger coming out of the bottom of the syringe.
Hey, Scott! Great new “wrinkle” in the pushdosr epi tool! Sorry if someone already commented, but my only thought is that the 0.1 cc will just sit in the tubing haha!