Drugs that have to be administered as drips? Resources for drug administration/route?

[propofabulous]

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Hey all,

Any recs for a CA-1 for a resource that can be used not for dosing but rather administration/route of the drugs we use? Sometimes I am told to give a drug I am not familiar with, and am unable to find out (via web or hospital pharmacy) the best way/timing to give it.

More importantly, I simply want to know what drugs I should AVOID giving IV push that could be harmful to the patient (ex. Vanc). Any recommendations? Thank you all in advance!

 

[deleted162650]

As a general rule as a CA-1, there's no shame in asking your attending any time you are giving a drug you have never given before.

 

[ZzzPlz]

Agree. You can always call for help

Just remember that calling for help is a sign of weakness

🤣

 

[deleted162650]

Just remember that calling for help is a sign of weakness

Call me if you need me. . . but NEED me if you call me 😉.

 

[rakotomazoto]

Always ask if you are unsure. What if you make an error that leads to a complication? What are you going to say when defending your management? "I googled it and then just went for it". If you want to be smart, do some research and call your attending to present your plan and get his/her approval, you don't need to just call up and ask how to do things without doing any homework. For those quick questions, uptodate is one source that I like personally, but others might favor anesthesia textbooks/handbooks.

Even if you read something from a source that is somewhat reputable, your attending might just prefer to do things a different way. I remember giving 5mg of labetolol during a case as an intern (we did one month of anesthesia) and being proud of myself for applying what I had read in a textbook the night before. I had already deepened the sedation and given some fentanyl, etc and the pressure was still high. My attending came in and saw the vial and lost it, going on a rant about how he NEVER give labetalol and always treats hypertension with fentanyl, fentanyl, and more fentanyl. Honestly, either option would not have resulted in serious harm, but you are making first impressions as a CA-1, not trying to prove that you already know the things that your attendings are supposed to be teaching you for the next 3 years.

Good attendings will never fault you for confirming what you plan to do if you have never done it before. Those are the ones whose opinions matter most. One day, your future employer will call people they trust and ask them about how you were as a resident.

 

[jwk]

Hey all,

Any recs for a CA-1 for a resource that can be used not for dosing but rather administration/route of the drugs we use? Sometimes I am told to give a drug I am not familiar with, and am unable to find out (via web or hospital pharmacy) the best way/timing to give it.

More importantly, I simply want to know what drugs I should AVOID giving IV push that could be harmful to the patient (ex. Vanc). Any recommendations? Thank you all in advance!

Almost any drug we get is pre-compounded or unit dose from pharmacy. Any infusion we get has specific instructions on timing (often ignored except for vanc). Any pressors need a careful look, since they frequently need to be diluted to a manageable concentration (epi, neo, ephed, etc.) Most of the drugs we give, but certainly not all, can be pushed relatively rapidly. Same goes for blood - the blood bank policy the nurses have to follow is that a unit of blood has to be given over an hour. Fortunately that policy doesn't apply/is ignored in the OR.

 

[vector2]

Uptodate has good dosing, route, administration instructions for pretty much every med, but ask your attending first if you have any doubt.

Most antibiotics other than ancef are recommended to be given slowly (although we frequently ignore this and don't see side effects). Must give slowly off the top of my head: amiodarone, protamine, campath (and other mABs) for transplant, local anesthetics other than lido, dilt/verapamil (slow iv push recommended). Dexmedetomidine can cause crazy bradycardia, hypotension, or paradoxical hypertension when bolus doses are pushed. Heparin can cause transient hypotension when slamming >10,000 units IV. Would also administer typical antipsychotics with some caution when dosing IV.

 

[Ronin786]

While all this is important and anytime you give a drug you've never given before you should have your hazards on and ask an attending, but also remember that you are not a nurse and this is the OR and not the floor. Many infusion instructions are intended for floor/ICU administration over a longer period of time without the ability to immediately react to changes.

You've got an arsenal of medications and physiologic ability at your disposal. Don't be afraid to use it.

 

[deleted875186]

Just know that whatever medication or drip you start, when you bring your patient to the ICU they will disconnect all your drips and run them all separately through every port of your central line, every IV, then put some octopus looking splitters on the ports to make more ports, then ask the ICU team to put in another PICC line with three ports, all so no infusion will ever touch any other infusion. Then they will wonder why their patient is getting so much IV fluids when they have 10 different KVOs.

 

[deleted875186]

Also, OP also has a great screen name.

 

[deleted87051]

Just know that whatever medication or drip you start, when you bring your patient to the ICU they will disconnect all your drips and run them all separately through every port of your central line, every IV, then put some octopus looking splitters on the ports to make more ports, then ask the ICU team to put in another PICC line with three ports, all so no infusion will ever touch any other infusion. Then they will wonder why their patient is getting so much IV fluids when they have 10 different KVOs.

Except they are all mixing inside the patient.

 

[Aether2000]

IV Infusions Used During Anesthesia

 

[Ezekiel2517]

Provided it's diluted properly and given the appropriate context, any drug can be pushed. If you can push a mg of epinephrine into a patient, everything is fair game. It's about using your knowledge and best judgement

 

[narcotics999]

I heard a story of IVP Dilantin; pt coded on the table

As others mentioned, if you are not sure, ask your seniors, attendings.

Medscape has a good app for drugs administration, doses, indications, contraindications, kinetics, etc. It is free.

 

[deleted87051]

I heard a story of IVP Dilantin; pt coded on the table

Isn’t that the best place to code?

There’s also this thread.

Antibiotic infusion rate

 

[pgg]

Except they are all mixing inside the patient.

That's what I used to tell my kids when they'd freak out if a vegetable touched the mashed potatoes.

 

[Ronin786]

FWIW, certain medications, particularly piperacillin/tazobactam, need to be administered as extended infusions to ensure that their concentrations remain above the MIC and are actually effective.

Rationale and evidence for extended infusion of piperacillin-tazobactam. - PubMed - NCBI

 

[Iso4ane]

I wouldn't go too crazy with protamine for heparin reversal.

But, I do remember once when (I think NSGY) wanted to reverse a heparin drip with protamine, which they ordered from pharmacy. When it arrived to the room the circulater stated that the pharmacy stress that half be given over ~10mins and the second half over 8 hours. Total dose? 50mg. Talk about slow infusion, if we reversed like that in the cardiac ORs, we'd get a lot more sudoku done.

 

[jwk]

I wouldn't go too crazy with protamine for heparin reversal.

But, I do remember once when (I think NSGY) wanted to reverse a heparin drip with protamine, which they ordered from pharmacy. When it arrived to the room the circulater stated that the pharmacy stress that half be given over ~10mins and the second half over 8 hours. Total dose? 50mg. Talk about slow infusion, if we reversed like that in the cardiac ORs, we'd get a lot more sudoku done.

This was a common concern when every IDDM patient was taking NPH insulin. Not terribly common anymore, and I haven't seen hypotension from protamine in many years. It was quite impressive though in the old days.

 

[Iso4ane]

This was a common concern when every IDDM patient was taking NPH insulin. Not terribly common anymore, and I haven't seen hypotension from protamine in many years. It was quite impressive though in the old days.

I once gave 100mg as a push, that caused some hypotension...

 

[anbuitachi]

i would recommend giving potassium as an infusion and not IVP

 

[deleted162650]

i would recommend giving potassium as an infusion and not IVP

An attending in residency had me slowly hand bolus potassium from a 60cc syringe once. My response, “Ummm, OK. You’re gonna stay in the room right?”