Cheat sheet for mixing drips/bags?

[TheTruckGuy]

Pharmacy friends. I'm an ED resident and looking to see if any of you have a handy cheat sheet on how to mix up various critical drips. Sometimes I rotate at community EDs where there might be one overworked pharmacist tucked away in a dungeon somewhere, and trying to get them to make up an epi drip or bicarb drip and send it to the ED will take way too long if we have a critical patient. And sometimes you're with nurses that aren't very experienced, and I have to tell them exactly what to do.

I know how to make push dose epi, and put 1mg in 1L to make a dirty epi drip. But I know I've worked at places where they make low concentration epi for peripheral lines, and high concentration for central lines. I think 4mcg/ml vs 16mcg/mL, but I could be wrong.

And then what about bicarb drips? I had a critical code the other night and couldn't recall if I put 3 amps bicarb in D5W or D5 1/2 NS.

And one place I worked at I remember the pharmacy sending up a bag of "max concentrate" bicarb. What's that? I suspect that needs to come from y'all right?

Drop some knowledge on me.

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[storyhill2]

I have a folded up paper in my desk drawer. I carry it with me to any acute situation. Some pharmacist before me had made up a "word" document with many meds we use in critical situations with their doses. I have just had that list printed up and I write on it anything I wish I would have known in the last critical situation. After a while you get all of the things you need. I know that's not the best answer but there doesn't seem to be a great premade list somewhere with things on it. For example I have written on there the different magnesium indications and their different dilutions and infusion times; heparin reversal dosing calculations ( in one situation in icu where person was in cardiac arrest with probably 8 people in the room, we got rosc, but then the doc thought the patient had an internal bleed and everyone looked at me and the doc asked me to reverse the heparin drip but I couldn't leave the unit to look up stuff because they need me there, so I later wrote down a good website for a quick reversal calculator); amiodarone dilutions, administration lengths and doses. For sodium bicarb in acute situation usually just give it push. By max concentration I think they mean 150meq of sodium bicarbonate in 1 liter of something. I think it it gets too high osmolarity after that. As far as what to dilute sodium bicarbonate I usually stick with sterile water or D5w. Going with the sodium chloride increases the osmolarity too much and the sodium content becomes a concern. We keep components in our crash kit for us to make an epinephrine drip regular concentration at bedside and also amiodarone piggy back bedside. OK, sorry this isn't organized that well. I'm just spouting things I think might be helpful for you. I have tried to bring my phone with access to "lexicomp" and "uptodate" but the app is so glitchy that it is not helpful often. Sometimes i just quick go to my desk nearby and look something up. I also have my work provided phone with me and call central pharmacy and ask my pharmacist co worker to look something up and tell me some info. Norepi drips are premix. I sometimes will carry one in my pocket if I think it's going to be needed. Lots of stuff you just memorize. initial drip rates, titration schedules....etc.

 

[Dred Pirate]

put 1mg in 1L to make a dirty epi drip ??
I have been an ED rph for 18 years and never heard of 1 mg in 1 L - in what case would you use this?

but honestly each hospital might have different standard concentrations, so just get a list from a regular ED rph or the IV room compensium and make your own cheat sheet until you get comfortable enough having them memorized. Better yet, get badge cards made with them so you always have.


PS- you shouldn't have to make push dose epi- get your IV room to have pre-filled syringes - you are likely doing a double dilution (or single dilution if you use the code epi) to get push dose epi - and you are just asking for errors. Not sure if your shop has 24/7 rph coverage (ours dose but most don't) - and if you are making on the fly, you are seriously asking for an error to happen if you ask a RN to do so.

 

[Dred Pirate]

I have a folded up paper in my desk drawer. I carry it with me to any acute situation. Some pharmacist before me had made up a "word" document with many meds we use in critical situations with their doses. I have just had that list printed up and I write on it anything I wish I would have known in the last critical situation. After a while you get all of the things you need. I know that's not the best answer but there doesn't seem to be a great premade list somewhere with things on it. For example I have written on there the different magnesium indications and their different dilutions and infusion times; heparin reversal dosing calculations ( in one situation in icu where person was in cardiac arrest with probably 8 people in the room, we got rosc, but then the doc thought the patient had an internal bleed and everyone looked at me and the doc asked me to reverse the heparin drip but I couldn't leave the unit to look up stuff because they need me there, so I later wrote down a good website for a quick reversal calculator); amiodarone dilutions, administration lengths and doses. For sodium bicarb in acute situation usually just give it push. By max concentration I think they mean 150meq of sodium bicarbonate in 1 liter of something. I think it it gets too high osmolarity after that. As far as what to dilute sodium bicarbonate I usually stick with sterile water or D5w. Going with the sodium chloride increases the osmolarity too much and the sodium content becomes a concern. We keep components in our crash kit for us to make an epinephrine drip regular concentration at bedside and also amiodarone piggy back bedside. OK, sorry this isn't organized that well. I'm just spouting things I think might be helpful for you. I have tried to bring my phone with access to "lexicomp" and "uptodate" but the app is so glitchy that it is not helpful often. Sometimes i just quick go to my desk nearby and look something up. I also have my work provided phone with me and call central pharmacy and ask my pharmacist co worker to look something up and tell me some info. Norepi drips are premix. I sometimes will carry one in my pocket if I think it's going to be needed. Lots of stuff you just memorize. initial drip rates, titration schedules....etc.

I think your rambling reminds me of myself - lol

You make good points, some stuff you just learn over the years, like it would be impossible for me to make a "cheat sheet" for my job simply bc there is so much randomness that I have put through this thick skull of mine. You start with a lot of references, and now I literally carry nothing other than my phone (which I only use for EMRA abx app and the calculator) - anything else I truly need stat I know, anything else, I have the 3 mintues it takes to find the answer.

 

[Rockinacoustic]

put 1mg in 1L to make a dirty epi drip ??
I have been an ED rph for 18 years and never heard of 1 mg in 1 L - in what case would you use this?

but honestly each hospital might have different standard concentrations, so just get a list from a regular ED rph or the IV room compensium and make your own cheat sheet until you get comfortable enough having them memorized. Better yet, get badge cards made with them so you always have.


PS- you shouldn't have to make push dose epi- get your IV room to have pre-filled syringes - you are likely doing a double dilution (or single dilution if you use the code epi) to get push dose epi - and you are just asking for errors. Not sure if your shop has 24/7 rph coverage (ours dose but most don't) - and if you are making on the fly, you are seriously asking for an error to happen if you ask a RN to do so.

Your EMS has never rolled in a ROSC on a dirty epi drip?

 

[Dred Pirate]

Yes. Dirty epi drips all the time. But they are never 1 in a liter. They are 8 in 250. It is 32x the concentration I guess I don’t get the point of such a low dose.

 

[RXDOC1986]

Every hospital system has their own standards and practices. You wouldn't want a cheat sheet from any of us. That would put you at a huge risk when you report to the M&M meeting the next morning after a patient has expired in your ED. You will be surprised how many different ways you can compound a Bicarb Drip according to your hospital Policy and Procedures.
There should also be ED code boxes with everything you need and directions how YOUR hospital wants you to mix them. If there are no such resources provided, which is unheard of, I would get out of there ASAP.

 

[TheTruckGuy]

put 1mg in 1L to make a dirty epi drip ??
I have been an ED rph for 18 years and never heard of 1 mg in 1 L - in what case would you use this?

but honestly each hospital might have different standard concentrations, so just get a list from a regular ED rph or the IV room compensium and make your own cheat sheet until you get comfortable enough having them memorized. Better yet, get badge cards made with them so you always have.


PS- you shouldn't have to make push dose epi- get your IV room to have pre-filled syringes - you are likely doing a double dilution (or single dilution if you use the code epi) to get push dose epi - and you are just asking for errors. Not sure if your shop has 24/7 rph coverage (ours dose but most don't) - and if you are making on the fly, you are seriously asking for an error to happen if you ask a RN to do so.

Yeah, nurses will often do 4mg in 250cc bag for a standard epi drip. But that takes a little longer to make than just throwing 1mg in a 1L bag. Depending on how many nurses are available, often times I'll have a nurse just make that and hang it as soon as we receive a code in process, or early on if a patient codes. Run it in at roughly 1mcg/kg/min and spread out push dose epi closer to every 4-5 minutes rather than every 3-5 minutes. And then if we get ROSC, the drip is going and I'll titrate it down to 0.5mc/kg/min, and then slowly down as much as possible. And if a pump isn't on hand right away can eyeball the drip rate while the code is ongoing. Some places actually will start the code with 1mg of epi, and if they don't get ROSC within a few minutes will follow it with 2mg in a 1L bag that they then pressure bag into the patient. Obviously post ROSC, when things have calmed a bit, transition to more formal drips.

At one of the shops I worked at, 2 years ago, during COVID the 24 person ED had 10-15 holds, 2 nurses (not including triage), and about 4 techs, with 10-30 in the waiting room on any given night. Oh, and would get the occasional GSW drop off. My anxiety still kicks up a notch every time I think about it. But they've since hired a bunch of travel nurses, and the volume has trended down a bit, so it's a lot better.

If I'm making push dose epi (10mcg/ml), I'm doing that myself, or watching the nurse do it. We've got the Neosticks (1000mcg phenylephrine in a 10cc syringe) at some places. They work in a pinch, but I don't really like them.

 

[Dred Pirate]

Is dirty epi a term?

just means it is made outside of a clean room (at least that is how we use it)

 

[KidPharmD]

First, unless 1L bags is all you have or 1mcg/mL is the standard epi drip concentration, do 1mg into a 250mL bag to get 4mcg/mL. At least that is a normal concentration for epi.

Second, I am going to agree that you don't want a cheat sheet from us if you are working at multiple shops. Bedside epi is normal at least, but bedside bicarb drip is risky for everyone, especially one that doesn't do it often.

 

[Dred Pirate]

First, unless 1L bags is all you have or 1mcg/mL is the standard epi drip concentration, do 1mg into a 250mL bag to get 4mcg/mL. At least that is a normal concentration for epi.

plus it avoids an accidental 1mg bolus if some thinks the bag is just plain NS and they run it in on a pressure bag - although at that point the 1mg epi might be needed,

 

[Dred Pirate]

Yeah, nurses will often do 4mg in 250cc bag for a standard epi drip. But that takes a little longer to make than just throwing 1mg in a 1L bag. Depending on how many nurses are available, often times I'll have a nurse just make that and hang it as soon as we receive a code in process, or early on if a patient codes. Run it in at roughly 1mcg/kg/min and spread out push dose epi closer to every 4-5 minutes rather than every 3-5 minutes. And then if we get ROSC, the drip is going and I'll titrate it down to 0.5mc/kg/min, and then slowly down as much as possible. And if a pump isn't on hand right away can eyeball the drip rate while the code is ongoing. Some places actually will start the code with 1mg of epi, and if they don't get ROSC within a few minutes will follow it with 2mg in a 1L bag that they then pressure bag into the patient. Obviously post ROSC, when things have calmed a bit, transition to more formal drips.



If I'm making push dose epi (10mcg/ml), I'm doing that myself, or watching the nurse do it. We've got the Neosticks (1000mcg phenylephrine in a 10cc syringe) at some places. They work in a pinch, but I don't really like them.

does it really take much longer to draw up 4ml? (not sure if you have the 30mg/30ml vial availalbe) or you might just use 4 x 1 ml vials - still, doesn't take that long.

1 mcg/kg/min - you do weight based epi for adults? If you have a typical 100kg person - that means you are running it at 100ml an minute - so that 1 liter bag only lasts 10 min?

I think you need to clarify "push dose epi" how you stated - I think you are talking about code epi ever 3-5 minutes - if you are pushing epi in a code, no need to mess with a IVPB/drip - start that once you get rosc.

Just get your IV room to make the push dose epi (10 mcg/ml) - so very very very much easier - how do you make it? what products do you use?

This convo reminds me of when I tried to teach a RN how to adjust the rate counting the drips - then an old grizzeled ICU RN comes up to me - "darling, don't waste your time trying to teach this young generation that- they can't do anything that doesn't use a pump, bless their hearts"

 

[TheTruckGuy]

does it really take much longer to draw up 4ml? (not sure if you have the 30mg/30ml vial availalbe) or you might just use 4 x 1 ml vials - still, doesn't take that long.

1 mcg/kg/min - you do weight based epi for adults? If you have a typical 100kg person - that means you are running it at 100ml an minute - so that 1 liter bag only lasts 10 min?

I think you need to clarify "push dose epi" how you stated - I think you are talking about code epi ever 3-5 minutes - if you are pushing epi in a code, no need to mess with a IVPB/drip - start that once you get rosc.

Just get your IV room to make the push dose epi (10 mcg/ml) - so very very very much easier - how do you make it? what products do you use?

This convo reminds me of when I tried to teach a RN how to adjust the rate counting the drips - then an old grizzeled ICU RN comes up to me - "darling, don't waste your time trying to teach this young generation that- they can't do anything that doesn't use a pump, bless their hearts"

1mcg/kg/min as an estimate. I might go higher or lower depending on what the patient looks like. Have never gone above 100mcg/min. I had a 250kg patient code a few weeks back. We didn't run a drip on him till post ROSC, but no, on him I would've probably capped at 100mcg/min during the code. And yeah, it doesn't follow the ACLS algorithm. However there is some hypothetical benefits to less frequent slams of epi to the heart and circulation. Another advantage is it's already there and hanging post ROSC and can just be titrated down. Probably voodoo, but as far as I know, no harm, and potential for some benefit.

Sorry, I think in one instance I meant to say code dose epi but said push doses.

When I make push dose for peri-intubation pressure support, or something like that, usually take 1mL of 1:10000 code dose epi and mix it with 9mL of NS, and swirl the syringe a few times.

 

[Dred Pirate]

1mcg/kg/min as an estimate. I might go higher or lower depending on what the patient looks like. Have never gone above 100mcg/min. I had a 250kg patient code a few weeks back. We didn't run a drip on him till post ROSC, but no, on him I would've probably capped at 100mcg/min during the code. And yeah, it doesn't follow the ACLS algorithm. However there is some hypothetical benefits to less frequent slams of epi to the heart and circulation. Another advantage is it's already there and hanging post ROSC and can just be titrated down. Probably voodoo, but as far as I know, no harm, and potential for some benefit.

Sorry, I think in one instance I meant to say code dose epi but said push doses.

When I make push dose for peri-intubation pressure support, or something like that, usually take 1mL of 1:10000 code dose epi and mix it with 9mL of NS, and swirl the syringe a few times.

PS- I actually enjoy having a clinical discussion on this board!

gotta love those 250kg codes, I remember coding a 600+ lb guy- I was essentially throwing my whole weight into him doing CPR bc the the RN was like 100 lbs and would probably have to climb up on him and jump on him like a trampoline to get effective CPR.

I never really thought about the the drip + lower pushes as having a benefit, it does make sense, but as we all know what makes hypothetical benefit doesn't always translate, but I get it. It does complicate things a little as you don't want to give "too much" epi, but also don't want to under dose it, but then again, in a code we do so much that actually doesn't have any evidence behind it.

Do your docs ever just stop giving epi at some point even thou the code continues? I mean, once we get to double figures, is the epi really going to help??

as far as push dose, that is one way to make it (probably the best) - some time people don't know how to get the 1 ml out of the abboject and just make a mess of it. But it is better than doing a double dilution (1 mg/1ml epi into a 9 ml flush, then taking 1 ml of that and putting into another 9 ml fush- I have seen people do that, but it is just ripe with errors for obvious reasons)

 

[PharmDBro2017]

Explain the terminology, why "dirty epi drip". Is clean made in the cleanroom? Lol, never heard that lingo before.

 

[Dred Pirate]

Explain the terminology, why "dirty epi drip". Is clean made in the cleanroom? Lol, never heard that lingo before.

that is exactly the reason.
also sorta "quick and dirty"
Basically it falls into the immediate use provision, and needs to be replaced with a "clean" one as soon as feesible.

 

[PharmDBro2017]

Makes sense. Nice that the new BUD for immediate use is 4 hours come Nov 1st.

 

[TheTruckGuy]

PS- I actually enjoy having a clinical discussion on this board!

gotta love those 250kg codes, I remember coding a 600+ lb guy- I was essentially throwing my whole weight into him doing CPR bc the the RN was like 100 lbs and would probably have to climb up on him and jump on him like a trampoline to get effective CPR.

I never really thought about the the drip + lower pushes as having a benefit, it does make sense, but as we all know what makes hypothetical benefit doesn't always translate, but I get it. It does complicate things a little as you don't want to give "too much" epi, but also don't want to under dose it, but then again, in a code we do so much that actually doesn't have any evidence behind it.

Do your docs ever just stop giving epi at some point even thou the code continues? I mean, once we get to double figures, is the epi really going to help??

as far as push dose, that is one way to make it (probably the best) - some time people don't know how to get the 1 ml out of the abboject and just make a mess of it. But it is better than doing a double dilution (1 mg/1ml epi into a 9 ml flush, then taking 1 ml of that and putting into another 9 ml fush- I have seen people do that, but it is just ripe with errors for obvious reasons)

Yeah, at some point too much epi can actually be making things worse. I'm sure you've seen this before, but sometimes epi will convert someone from PEA to VFib. But if they were VFib to begin with, more epi just makes the ventricles fibrilate more and sometimes makes it refractory to electricity secondary to increased mycardial oxygen demand and the pro-arrythmic effect of that.

I haven't done it before, but some people have started trying esmolol drips during these kinds of codes. After a few rounds of epi and defibs, initiate some betablockade to help the heart relax a little. Some people have also done dual sequential defibs where you're essentially pressing the defib button at the same time on 2 Lifepaks. There's a lot of debate on how it works, if it works, etc., and the data isn't really there to support it yet. But a reasonable number of anecdotes to make me at least consider it if I needed.

Some people also continue CPR during defibs. Some will not necessarily do compressions, but will just put a sheet down and squeeze the chest to decrease the space between the pads and the heart.

But yea, you're totally right. At that point, the patient is dead, we're throwing everything we can at them to undead them, whether or not it has been proven to work or not.

 

[Dred Pirate]

Yeah, at some point too much epi can actually be making things worse. I'm sure you've seen this before, but sometimes epi will convert someone from PEA to VFib. But if they were VFib to begin with, more epi just makes the ventricles fibrilate more and sometimes makes it refractory to electricity secondary to increased mycardial oxygen demand and the pro-arrythmic effect of that.

I haven't done it before, but some people have started trying esmolol drips during these kinds of codes. After a few rounds of epi and defibs, initiate some betablockade to help the heart relax a little. Some people have also done dual sequential defibs where you're essentially pressing the defib button at the same time on 2 Lifepaks. There's a lot of debate on how it works, if it works, etc., and the data isn't really there to support it yet. But a reasonable number of anecdotes to make me at least consider it if I needed.

Some people also continue CPR during defibs. Some will not necessarily do compressions, but will just put a sheet down and squeeze the chest to decrease the space between the pads and the heart.

But yea, you're totally right. At that point, the patient is dead, we're throwing everything we can at them to undead them, whether or not it has been proven to work or not.

esmolol- there is evidence to use it in sudden sniffing death syndrome - I used it for the first time in a code a month or two ago - unfortunately it didn't work

We have been dual shocks awhile - and generally I have not seen it beneficial - and ya the evidence is all over the place with that.

I work with a guy who had a doc at his old hospital who would continue to do compressions while they shocked - he didn't expect anyone else to do it, but he never had issues - which surprises me.

 

[Rockinacoustic]

A couple thoughts on your scenarios:

• Do you not have pre-mixed Norepi drips available in the ED? These are more readily available than pre-mixed Epi drips, and frankly there's as good evidence for Norepi as there is for using an Epi infusion for Post-ROSC Shock. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock - PubMed
• If you're set on an Epi drip, ask your pharmacy to stock enough 1mg/ml vials in your crash cart so you can mix an infusion pursuant to the concentration your IV pump library has. Keep a copy of your site's IV guideline/titratables handy.
• I can't think of a situation where a bicarb drip is needed emergently...? Why wouldn't pushing 1-2mEq/kg (2-3 amps) of a 8.4% Sodium Bicarb bristoject be as effective until a drip is compounded? These should be in your code carts.
• I have used esmolol for refractory vfib a few times, and like everything else is ACLS, results may vary.
• Keep in mind I'm speaking as a pharmacist exclusively working in the ED, so I make these "fancier" resus things happen fast without pulling an RN or provider away from the patient.

 

[PharmDBro2017]

Been keeping premix double strength (8mg/250mL) and quad strength norepi (16mg/250mL) in the ICU for a year or longer now, it has been a game changer.

Diff subject (antibiotics...) but premix vanc = massive game changer too

Baxter is releasing premix daptomycin (350mg/500mg/700mg/1000mg) over the next month which will be fantastic too. Really need an 850mg though.

 

[Sparda29]

Pharmacy friends. I'm an ED resident and looking to see if any of you have a handy cheat sheet on how to mix up various critical drips. Sometimes I rotate at community EDs where there might be one overworked pharmacist tucked away in a dungeon somewhere, and trying to get them to make up an epi drip or bicarb drip and send it to the ED will take way too long if we have a critical patient. And sometimes you're with nurses that aren't very experienced, and I have to tell them exactly what to do.

I know how to make push dose epi, and put 1mg in 1L to make a dirty epi drip. But I know I've worked at places where they make low concentration epi for peripheral lines, and high concentration for central lines. I think 4mcg/ml vs 16mcg/mL, but I could be wrong.

And then what about bicarb drips? I had a critical code the other night and couldn't recall if I put 3 amps bicarb in D5W or D5 1/2 NS.

And one place I worked at I remember the pharmacy sending up a bag of "max concentrate" bicarb. What's that? I suspect that needs to come from y'all right?

Drop some knowledge on me.

Global RPH Website -> Dilutions -> Choose Drug

Epinephrine (Epinephrine for example)

Find out all the drugs you need to know and make your own little cheat sheet.

 

[Sparda29]

put 1mg in 1L to make a dirty epi drip ??
I have been an ED rph for 18 years and never heard of 1 mg in 1 L - in what case would you use this?

but honestly each hospital might have different standard concentrations, so just get a list from a regular ED rph or the IV room compensium and make your own cheat sheet until you get comfortable enough having them memorized. Better yet, get badge cards made with them so you always have.


PS- you shouldn't have to make push dose epi- get your IV room to have pre-filled syringes - you are likely doing a double dilution (or single dilution if you use the code epi) to get push dose epi - and you are just asking for errors. Not sure if your shop has 24/7 rph coverage (ours dose but most don't) - and if you are making on the fly, you are seriously asking for an error to happen if you ask a RN to do so.

Yeah, we usually do 1 mg in 250 mL or 4 mg in 1000 mL.

 

[storyhill2]

Great to see a small community of us pharmacists that have experience in these things. I was reading through a lot of the comments and had some other thoughts from my experience.

Do you not have pre-mixed Norepi drips available in the ED? These are more readily available than pre-mixed Epi drips, and frankly there's as good evidence for Norepi as there is for using an Epi infusion for Post-ROSC Shock. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock - PubMed

does it really take much longer to draw up 4ml? (not sure if you have the 30mg/30ml vial availalbe)

- Even though sometimes I can make a recommendation or get a doc to change what med they have requested more often the doctor knows the different options and some prefer the epinephrine drip and some prefer norepi drips. The norepinephrine drips are premix, which is easy. We stock large vials of epinephrine and 250ml bags of fluid so we can just make 4 mg/250ml at the bedside. (we use the same product as "dred pirate" mentioned above) It's a good setup.
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- There were many references to dirty epi. My understanding is that it is just trying to use the components that are most commonly available and are able to be made quickly in most environments as a short term patch until something more standard can be given. Most everyone has access to 1 mg epi and a liter bag of fluid. There are few docs that ask me to make a "dirty epi" and I understand them to mean 1 mg in 1 liter bag. I tell them that I can make a standard Epinephrine drip about as fast and they say agree instantly. My drip is made bedside but I still don't think it would be considered a "dirty epi".

I can't think of a situation where a bicarb drip is needed emergently...? Why wouldn't pushing 1-2mEq/kg (2-3 amps) of a 8.4% Sodium Bicarb bristoject be as effective until a drip is compounded? These should be in your code carts.

- Totally agree, if they ask for a bicarb drip at some point I'm calling pharmacy to make one up and deliver. I usually get it in 5-10 minutes. In the acute situation it almost always calls for sodium bicarb 50 ml pushes that should be in your med tray.

Do your docs ever just stop giving epi at some point even thou the code continues? I mean, once we get to double figures, is the epi really going to help??

- I am wondering the same thing. This happened to me a few days ago. Can you answer your question too? I have had it happen a few times where they are still giving compressions and I speak out and say, "it's been 3 minutes since last epi", and the doc will say they don't want to give any more epi. I am wondering, why are we still doing compressions then? This usually happens right at the end. I feel like they already have it in their heads that it's over but want to finish the last round of compression and check for a pulse. Maybe others have this occur with long periods of compressions and no epi? The few times it's happened to me it's been called deceased within 5 minutes.

you shouldn't have to make push dose epi- get your IV room to have pre-filled syringes -

- My hospital doesn't use it enough to make that necessary and there are really only a few docs who seem to want this. I tried to make a educational sheet for the nurses but pharmacy management didn't like that idea. So if a doc wants a push dose epi made up, they will make it themselves sometimes and if I am there then I make it. The docs like to have a pharmacist around so all their medication wishes can come true. We don't have 24 hr coverage in the ED.

esmolol- there is evidence to use it in sudden sniffing death syndrome - I used it for the first time in a code a month or two ago - unfortunately it didn't work

- interesting. I've never encountered this idea. I'll have to look into that.
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my most interesting use of epinephrine was last year a patient coded during surgery so that their heart was exposed. The surgeon literally squirting the epinephrine directly into the heart. I was on the side so I couldn't exactly where it was going, but I was so confused. He asked me to give him sterile epinephrine. I said I don't know what that means but that the epinephrine product was in a box. He had his nurse squirt it into a bowl in the sterile field and then he sucked it back up into a syringe before he administered.
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Gotta get back to work!

 

[Rockinacoustic]

Might be an unpopular opionion, but I find limited utility for push dose pressors in the ED... most patient presentations aren't going to have their shock resolve after 20-30mcg of epi, and i really dislike using neo sticks in undifferentiated shock that could be a PE.

Just ask your team to come to every resus with a bag of norepi ready to go peripherally.

 

[Sparda29]

Great to see a small community of us pharmacists that have experience in these things. I was reading through a lot of the comments and had some other thoughts from my experience.




- Even though sometimes I can make a recommendation or get a doc to change what med they have requested more often the doctor knows the different options and some prefer the epinephrine drip and some prefer norepi drips. The norepinephrine drips are premix, which is easy. We stock large vials of epinephrine and 250ml bags of fluid so we can just make 4 mg/250ml at the bedside. (we use the same product as "dred pirate" mentioned above) It's a good setup.
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- There were many references to dirty epi. My understanding is that it is just trying to use the components that are most commonly available and are able to be made quickly in most environments as a short term patch until something more standard can be given. Most everyone has access to 1 mg epi and a liter bag of fluid. There are few docs that ask me to make a "dirty epi" and I understand them to mean 1 mg in 1 liter bag. I tell them that I can make a standard Epinephrine drip about as fast and they say agree instantly. My drip is made bedside but I still don't think it would be considered a "dirty epi".


- Totally agree, if they ask for a bicarb drip at some point I'm calling pharmacy to make one up and deliver. I usually get it in 5-10 minutes. In the acute situation it almost always calls for sodium bicarb 50 ml pushes that should be in your med tray.


- I am wondering the same thing. This happened to me a few days ago. Can you answer your question too? I have had it happen a few times where they are still giving compressions and I speak out and say, "it's been 3 minutes since last epi", and the doc will say they don't want to give any more epi. I am wondering, why are we still doing compressions then? This usually happens right at the end. I feel like they already have it in their heads that it's over but want to finish the last round of compression and check for a pulse. Maybe others have this occur with long periods of compressions and no epi? The few times it's happened to me it's been called deceased within 5 minutes.


- My hospital doesn't use it enough to make that necessary and there are really only a few docs who seem to want this. I tried to make a educational sheet for the nurses but pharmacy management didn't like that idea. So if a doc wants a push dose epi made up, they will make it themselves sometimes and if I am there then I make it. The docs like to have a pharmacist around so all their medication wishes can come true. We don't have 24 hr coverage in the ED.


- interesting. I've never encountered this idea. I'll have to look into that.
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my most interesting use of epinephrine was last year a patient coded during surgery so that their heart was exposed. The surgeon literally squirting the epinephrine directly into the heart. I was on the side so I couldn't exactly where it was going, but I was so confused. He asked me to give him sterile epinephrine. I said I don't know what that means but that the epinephrine product was in a box. He had his nurse squirt it into a bowl in the sterile field and then he sucked it back up into a syringe before he administered.
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Gotta get back to work!

5-10 mins? LOL at my place, they take their sweet ass time from answering the phone to sending a label to the IV room, to telling whoever is in the IV to make something then the IV person takes their time garbing up etc, next thing you know it's 30 mins.


I find it bizarre how doctors will spend 5 mins on a code with one patient and then call time of death but with other patients (younger, lower 20s, teens, kids) they will do ACLS for beyond an hour. We had a teenager come in for severe vomiting last year. They started having respiratory issues at CATSCAN, somehow during intubation they ****ed up and put the tube down the esophagus. A few mins later they coded and while doing CPR they were trying to figure out why the stomach was getting bigger and they realized their mistake. But they kept ACLS going for a while and even at one point opened up the patient to do heart massage. They called time of death over an hour after the heart stopped. What's the point of going that long?

 

[nickw2401]

Its going to vary from hospital to hospital...for example I never saw a 150 bicarb in a liter of NS at my previous hospital. I also see norepi drips of 32mg in 250 of NS or D5W at my current hospital when the most I saw before was 8mg/250ml

 

[PharmDBro2017]

Its going to vary from hospital to hospital...for example I never saw a 150 bicarb in a liter of NS at my previous hospital. I also see norepi drips of 32mg in 250 of NS or D5W at my current hospital when the most I saw before was 8mg/250ml

150mEq bicarb + 1 liter NS = hypertonic solution. You don't ever want to do that.

 

[TheTruckGuy]

5-10 mins? LOL at my place, they take their sweet ass time from answering the phone to sending a label to the IV room, to telling whoever is in the IV to make something then the IV person takes their time garbing up etc, next thing you know it's 30 mins.


I find it bizarre how doctors will spend 5 mins on a code with one patient and then call time of death but with other patients (younger, lower 20s, teens, kids) they will do ACLS for beyond an hour. We had a teenager come in for severe vomiting last year. They started having respiratory issues at CATSCAN, somehow during intubation they ****ed up and put the tube down the esophagus. A few mins later they coded and while doing CPR they were trying to figure out why the stomach was getting bigger and they realized their mistake. But they kept ACLS going for a while and even at one point opened up the patient to do heart massage. They called time of death over an hour after the heart stopped. What's the point of going that long?

I mean, it really depends. Witnessed arrest, in a hospital, in a young patient, is going to have the best chance at a meaningful outcome. Unwitnessed arrest, unknown downtime, in an old and sick person, even if you somehow get pulses back, chances of any meaningful outcome is low.

I've had EMS bring patients with unknown downtime. I try to get a finger stick glucose or i-stat chem 8 right away, and do one round of CPR/epi (if EMS hasn't given anything yet), and sick the ultrasound on the heart. If there's cardiac standstill, they're profoundly acidotic, severely hypoglycemic, etc., we're pretty much done. If I see heart movement, will continue.


Also depends on what we think caused it. PE requires at least 30 minutes of CPR after giving TPA, for example. And there have been people coded for over an hour with PE induced arrests that had complete recovery.

It really is a tough thing to call, because you never know when the next round of compressions or epi will make a difference and when it won't. Or if it's worth getting a pulse back in someone that's going to be brain dead. Like most things in medicine, there's a lot of nuance, and often no 100% clear answer everytime.

Thoracotomy on a medical code is pretty rare. Usually reserved for trauma. I've only ever put in chest tubes on medical codes because of pneumos after CPR, or spontaneous pneumos on ventilators. I don't think I'd ever cut into a chest unless an ultrasound/CXR showed something I could fix by doing so. Even then, would try to do it percutaneously if possible. In your case, I suspect once they realized they put it in the esophagus, they felt compelled to try harder to get him back.

I actually saw a case where anesthesia came down to a trauma and intubated. And the radiologist called urgently while they patient was in CT to let us know the tube was in the esophagus.... Don't know how they survived to be honest. I think they must've intubated with succs, or without paralytics or something.

 

[nickw2401]

150mEq bicarb + 1 liter NS = hypertonic solution. You don't ever want to do that.

its done many times....typically on neuro icu

 

[nickw2401]

ive seen 7% saline drips...and much higher pushes

 

[Dred Pirate]

its done many times....typically on neuro icu

in those cases you are aiming for high sodium levels to help with elevated IC pressure. You can make an argument of not having NS with 3 amps of bicarb orderable because the risk of inadvertent administration in anywhere but the NSICU is not worth the benefit it provides to those neuro patients patients when there are other options. You can always just run 3% or give 23.4% pushes and run the bicarb in D5W or sterile water.

it is a pro vs con arguement

 

[Sparda29]

You just work at a **** hospital. Not everyone does.

Do people at other hospital literally stay garbed up sitting in the IV room the whole shift? That's gotta suck for them.

I definitely don't work at a large hospital. But from what I've heard from people who do work at large hospitals in the NYC area, it's a lot more stressful and a lot easier to get fired.

 

[storyhill]

Do people at other hospital literally stay garbed up sitting in the IV room the whole shift? That's gotta suck for them.

I definitely don't work at a large hospital. But from what I've heard from people who do work at large hospitals in the NYC area, it's a lot more stressful and a lot easier to get fired.

If my fellow pharmacist in central pharmacy knows I am calling for something and need it quick they have the tech make it on the counter. They won't get garbed up. We also have a tube system that delivers most things within about 1 minute even though it's a 3 minute walk from the pharmacy to the ED. I usually don't even put in the order. I just call and give a verbal to the pharmacist, while the tech is gathering and compounding the central pharmacist is entering it and printing a label.

 

[Pharmist1720]

Do people at other hospital literally stay garbed up sitting in the IV room the whole shift? That's gotta suck for them.

I definitely don't work at a large hospital. But from what I've heard from people who do work at large hospitals in the NYC area, it's a lot more stressful and a lot easier to get fired.

At my institution we have 2-3 IV room techs garbed up in the clean room at all times. Yes it sucks and there's alot of turnover in those positions.

 

[Sparda29]

If my fellow pharmacist in central pharmacy knows I am calling for something and need it quick they have the tech make it on the counter. They won't get garbed up. We also have a tube system that delivers most things within about 1 minute even though it's a 3 minute walk from the pharmacy to the ED. I usually don't even put in the order. I just call and give a verbal to the pharmacist, while the tech is gathering and compounding the central pharmacist is entering it and printing a label.

Ah, no techs mixing IVs at my hospital. Only pharmacists allowed to do that.

 

[Dred Pirate]

Do people at other hospital literally stay garbed up sitting in the IV room the whole shift? That's gotta suck for them.

I definitely don't work at a large hospital. But from what I've heard from people who do work at large hospitals in the NYC area, it's a lot more stressful and a lot easier to get fired.

we have a tech garbed up working in the IV room 95% of the time not counting graveyard shift - they techs essentially take turns going and and out.

 

[Dred Pirate]

Ah, no techs mixing IVs at my hospital. Only pharmacists allowed to do that.

wow - really? that is very time consuming and not effective - although safer

 

[Rockinacoustic]

wow - really? that is very time consuming and not effective - although safer

Pretty sure it's a NY BOP law that only pharmacists can do sterile compounding

 

[Dred Pirate]

Pretty sure it's a NY BOP law that only pharmacists can do sterile compounding

gotcha - not familiar with NY law

 

[Sparda29]

Pretty sure it's a NY BOP law that only pharmacists can do sterile compounding

Not anymore. "Registered Pharmacy Technicians" may do sterile compounding. They have to have certification from NHA or PTCB and have undergone site specific training and have to be supervised by the pharmacist and their work checked by the pharmacist.

So a lot of the pharmacy techs employed by the hospitals are still not registered and I don't think they can be forced to register if they are union members.

 

[RXDOC1986]

Its going to vary from hospital to hospital...for example I never saw a 150 bicarb in a liter of NS at my previous hospital. I also see norepi drips of 32mg in 250 of NS or D5W at my current hospital when the most I saw before was 8mg/250ml

Yes, IV policy does vary from hospital to hospital, but some things just cannot be done. For example, 150meq of Sod.Bicarb, can only be compounded in D5W or St.Water, never in NS, due to osmolarity.

 

[RXDOC1986]

that is exactly the reason.
also sorta "quick and dirty"
Basically it falls into the immediate use provision, and needs to be replaced with a "clean" one as soon as feesible.

Or, more accurately named, "Table Top" compounding as per USP 797. Any IV drip can be made on a hard surface, for immediate infusion, and can hang for 24hrs, as BUD.

 

[storyhill]

Ah, no techs mixing IVs at my hospital. Only pharmacists allowed to do that.

Interesting. You mean only pharmacist can compound iv outside of the clean room? Or do you mean only pharmacist compound iv period? I have been in a lot of hospital pharmacies and have never seen that before. We would have to hire a lot more pharmacists.

 

[storyhill]

Interesting. You mean only pharmacist can compound iv outside of the clean room? Or do you mean only pharmacist compound iv period? I have been in a lot of hospital pharmacies and have never seen that before. We would have to hire a lot more pharmacists.

Ah, no techs mixing IVs at my hospital. Only pharmacists allowed to do that.

Sorry I just saw the other replies that answer this question. State law I guess?

 

[Sparda29]

Sorry I just saw the other replies that answer this question. State law I guess?

Yep. Well now it's been changed to allow certified registered technicians to do it. I wasn't a fan of this law that allows techs to do it. Restricting it to only pharmacists or pharmacy interns helps in forcing hospitals to hire more pharmacists than techs.

 

[njac]

just means it is made outside of a clean room (at least that is how we use it)

It’s term I’ve banned from our ED.

It can mean push dose. It can mean this 1mg/1L, it can mean 0.1mg/100ml (had an old doc who liked this for asthma)

If you (the physician) can not tell me exactly what dose you want you cannot have it.

We have premade epi drips (8mg/250ml) available so there’s no excuse for it other than residents wanting a new fun toy.