Cath Lab Code blue: 5 mg IC stacked epi? anyone experience this order?

[storyhill2]

Got called to cathlab today for cardiac arrest during surgery. One of the things the cardiologist wanted was "5 mg stacked epi" given intracardiac. I have had docs want to give epinephrine this route before when they were in surgery but not 5 mg. Has anyone else been asked to do this?

One of the ED docs went with me and he'd never heard of "stacked epi" before. When I got back to the ED I asked another doc and he said that it's code for " I'm the cardiologist and will do whatever the hell I want". He said it is actually an old school practice from about 20 years ago and has been abandoned long ago too because it wasn't helping in the long term. He thought the "stacked" meant back to back.

Just wondering if anyone else gets 5 mg or 3 mg Epinephrine dose orders in a code? We ended up just giving 1 mg because nobody thought he really wanted 5 mg at once. Got the guy back and he is in ICU but just wondering about anyone elses experience. Thanks.

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[Dred Pirate]

that is a new one for me- I have never seen more than 1 at time q 3 minutes. (and I have been to probably been to over 2,000 codes in my life.

 

[storyhill2]

that is a new one for me- I have never seen more than 1 at time q 3 minutes. (and I have been to probably been to over 2,000 codes in my life.

Thanks for the reply. Everyone:: A reply is helpful to me even if you've never done it:: 2000 codes. impressive. I'm around 200-400. 3 this week though.

 

[Dred Pirate]

Thanks for the reply. Everyone:: A reply is helpful to me even if you've never done it:: 2000 codes. impressive. I'm around 200-400. 3 this week though.

after almost 20 years they add up!! When I was nights I averaged probably 1 a night - x 160 shifts a year - you do that long and you lose track quickly

 

[Radetzky]

It’s a real old school thing from before we realized too much Epi is toxic

 

[storyhill2]

It’s a real old school thing from before we realized too much Epi is toxic

weird how those things can persist in some providers minds. "this is how i was trained in residency"

 

[sunnyandseventytwo]

It’s a real old school thing from before we realized too much Epi is toxic

I don't want to date myself, but the first time I did ACLS, escalating doses of epinephrine were still allowed. Too much epinephrine isn't toxic, there's a slight benefit over standard dosing at achieving ROSC, but survival to discharge is the same with either dose. The difference is you're keeping brain dead persons alive for an extra couple of days with higher dose epi.

 

[Dred Pirate]

I don't want to date myself, but the first time I did ACLS, escalating doses of epinephrine were still allowed. Too much epinephrine isn't toxic, there's a slight benefit over standard dosing at achieving ROSC, but survival to discharge is the same with either dose. The difference is you're keeping brain dead persons alive for an extra couple of days with higher dose epi.

I remember the escalating doses of epi- but I also vaguely remember readying recently you hit a ceiling at some point and it is just pointless, not sure if actual harm happens, or it is just wasteful, my record in a code was 22 mg total given (got ROSC on and off over 2-ish hours) but generally I can't think of giving more than 3-4 and actually getting meaningful recovery.

 

[Radetzky]

I don't want to date myself, but the first time I did ACLS, escalating doses of epinephrine were still allowed. Too much epinephrine isn't toxic, there's a slight benefit over standard dosing at achieving ROSC, but survival to discharge is the same with either dose. The difference is you're keeping brain dead persons alive for an extra couple of days with higher dose epi.

There certainly is toxicity with arrest from shockable rhythms. I will admit the data is not fantastic but it’s there. Or, at least, there is recognition too much adrenaline may not be a good thing in VF/VT arrest

 

[sunnyandseventytwo]

There certainly is toxicity with arrest from shockable rhythms. I will admit the data is not fantastic but it’s there. Or, at least, there is recognition too much adrenaline may not be a good thing in VF/VT arrest

Sure, all drugs have toxicity. On the whole, I think you'll find not worse outcomes with high dose vs. standard dose, though I haven't looked into this in years as the discussion is moot* with current guidelines.

Note: Has anyone else noticed that moot has two equal and opposite meanings? I say equal as it depends which site of the Atlantic you're on.

 

[Script1992]

The only question I got on epinephrine was from a ER RN asking if Epinephrine was compatible with D5W or NS. it can be either or.