How to Make Drips

[UW in 2002]

How do you make the following drips and what rates do you generally start at?

Remifentanyl
Epinephrine
Phenylephrine

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[bubalus]

Some pumps have standard concentrations for various infusions. If that's the case, then you're best off making them according to the standard. For example, Alaris Medley pumps use epinephrine at 4000 mcg in 250 ml. Vasopressin is 20 units/100 ml. Insulin is 100 units in 100 ml. Medfusion syringe pumps can be a little different.

I make my remi up at 50 mcg/ml, if I'm making it in solution by itself, i.e., not mixing it up in propofol for a one syringe TIVA.
I make my epi and phenylephrine up to whatever Alaris has as standard.

It's not the response you are looking for, but I start them at whatever rate I need them and titrate to effect.

 

[coprolalia]

How do you make the following drips and what rates do you generally start at?

Remifentanyl
Epinephrine
Phenylephrine

**DISCLAIMER**: Every hospital has a different mixing policy on drips. I am telling you what our policy is, and what I routinely do. There are several different ways you can make drips, including mixing them to "concentrated" to minimize amount of fluid you want to give to a patient.

Remifentanyl: One vial contains 2mg of liophylized remi. You take a 60 mL syringe and draw up 40mL of normal saline. You mix the remi in this 40mL of fluid. This will give you 50mcg/mL. Put it on a programmable syringe pump and run it at usually 0.3 to 0.7 mcg/kg/min. Some people run it at 1mcg/kg/min until they start to see an effect, but the last time I did this I had a severe chestwall rigidity (first one I'd seen) and I'm a little leary of doing this again.

Here's the remi PI:
http://www.rxabbott.com/pdf/ultiva.pdf

Epinephrine: Take a 250mL bag of normal saline. Draw up four 1mg vials (1:1000) of epinephrine and inject it into the bag. This will give you 16mcg/mL of epinephrine. You usually start VERY slowly with this drug, such as 0.05mcg/kg/min, and gently titrate up. You will almost never have to go above 1mcg/kg/min (with 0.4mcg/kg/min being pretty much a whopper dose) with this drug unless the patient is in complete doo-doo. This needs to be on a programmable pump.

Phenylephrine: Take a 250mL bag of normal saline. Draw up four 10mg vials of phenylephrine and inject it into the bag. This will give you 160mcg/mL of phenylephrine. This drug is not dosed based on weight at our institution, and we usually start at 25-50mcg/minute and titrate to effect. A usual target dose for someone with refractory hypotension is around 150-200mcg/min, but you should be searching for other causes before you (a) use this drug and (b) get to that dose (unless you are doing a neuro case and need to perfuse a cerebral vasospasm). This also needs to be on a programmable pump.

Good luck. Hope that helps.

-copro

 

[2ndyear]

One reason that there are hospital policies for this stuff is to not confuse handoffs in patient care. For example, I take over a CABG and get ready to come off pump. I want the epi, levo, neo, etc. to be the standard mixture so I can easily press a button and wham bam no confusion. Go to the CT-ICU and hand off the patient to the nurse and if the drips are standardized they don't have to sort through what concentration this and that is. The smarter the pump is the easier this is. So you press the epi selection, confirm that the concentration displaying is what's in the bag and there you go. We have some older syringe pumps that don't do this and it's one more chance for error. Selecting mcg/kg/min from a menu that has mcg/kg/hr, mcg/min, mL/min, mL/hr introduces this. I'm sure more than one person has run in Precedex at mcg/kg/min because of this.

On another note, do any of you have pharmacy mixed drips? We have premixed phenylephrine, dopamine, dobutamine. I think that's it. I like them, saves time and errors to some degree. Now if they would only do Precedex for me...

 

[VentdependenT]

How do you make the following drips and what rates do you generally start at?

Remifentanyl
Epinephrine
Phenylephrine

Never just hang a bag of epi on a mini dripper. Put it on a pump.

Same goes for KCL.

As for doses and starting rates, there are so many resources available to find that info, just grab a book and read it. Or a handbook.

Personally I make my Neosynephrine 100ucg per ml and Epi 32 ucg per ml (eight 1:1000 epi ml vials in a 250ml bag).

Personally I start neosynephrine at 10-20 ucg/min after a bolus dose (100 ucg or so).

Personally I start epinephrine ggt at 2-4 ucg after a bolus of whatever the hell I needed in the first place.

Levophed at 2-4 ucg starting dose. Once you are on this stuff youre in a bad bad place.

I rarely use dopamine or dobutamine. I occasionally use milrinone. I do use vasopressin at .04units/kg/min.

Its always best to have the pharmacy make your drips. They put nice big phat stickers with the dose on there and as such it may be less likely to be accidentally hung.

 

[jwk]

One reason that there are hospital policies for this stuff is to not confuse handoffs in patient care. For example, I take over a CABG and get ready to come off pump. I want the epi, levo, neo, etc. to be the standard mixture so I can easily press a button and wham bam no confusion. Go to the CT-ICU and hand off the patient to the nurse and if the drips are standardized they don't have to sort through what concentration this and that is. The smarter the pump is the easier this is. So you press the epi selection, confirm that the concentration displaying is what's in the bag and there you go. We have some older syringe pumps that don't do this and it's one more chance for error. Selecting mcg/kg/min from a menu that has mcg/kg/hr, mcg/min, mL/min, mL/hr introduces this. I'm sure more than one person has run in Precedex at mcg/kg/min because of this.

On another note, do any of you have pharmacy mixed drips? We have premixed phenylephrine, dopamine, dobutamine. I think that's it. I like them, saves time and errors to some degree. Now if they would only do Precedex for me...

Good point on the standard drips - each hospital has/should have a standardized system for any drug given by infusion. And if your hospital does have a standardized system, it's best not to do your own custom mix just because that's the way you like it.

I think the only drugs I've seen pre-mixed by the manufacturer that we carry are dopamine, but I would guess there are others. For us, anything we're likely to give by infusion is available from our satellite surgical pharmacy - if they don't make it up for us, the correct sized IV fluid, the correct number of ampules of whatever drug is being used, and a pre-printed label are all together in a ziploc bag and ready to mix.

 

[tussionex]

Its always best to have the pharmacy make your drips. They put nice big phat stickers with the dose on there and as such it may be less likely to be accidentally hung.

👍👍

your friendly pharmacy will happily make anything....and you'll get it quick if you're lucky enough to have an OR satellite.
we know ALL the house standards, so it's easy for us....and, if you really need something "non-standard", we can figure out how to make it work with the "smart-pumps"

 

[UTSouthwestern]

Never just hang a bag of epi on a mini dripper. Put it on a pump.

Same goes for KCL.

As for doses and starting rates, there are so many resources available to find that info, just grab a book and read it. Or a handbook.

Personally I make my Neosynephrine 100ucg per ml and Epi 32 ucg per ml (eight 1:1000 epi ml vials in a 250ml bag).

Personally I start neosynephrine at 10-20 ucg/min after a bolus dose (100 ucg or so).

Personally I start epinephrine ggt at 2-4 ucg after a bolus of whatever the hell I needed in the first place.

Levophed at 2-4 ucg starting dose. Once you are on this stuff youre in a bad bad place.

I rarely use dopamine or dobutamine. I occasionally use milrinone. I do use vasopressin at .04units/kg/min.

Its always best to have the pharmacy make your drips. They put nice big phat stickers with the dose on there and as such it may be less likely to be accidentally hung.

Putting a patient on Levophed doesn't always mean you are headed down the crapper. It is very useful with OPCABG's during bizarre positioning and the patients' do not develop tolerance to it as with neo.

Again, with OPCABG's, dobutamine is a good choice for inotropic support as the patients tend not to have a severe increase in HR, due to preop beta blockade, and the impact on SVR is minimal compared to milrinone.

I agree that having the OR pharmacy premake your infusions is a good idea but mistakes still happen:

Two months ago, I requested my standard OPCAB meds including norepi 8 mg/250cc. During the case I was having a tough time maintaining BP going as high as 8 mcg/min on the norepi. I shut off my Precedex, minimized volatile to a just at 1 MAC with the PSA showing patient adequately anesthetized, and still had problems although the patient responded promptly to 100 mcg boluses of neo. My final test was to draw 2 cc's from my norepi bag and give it IV push, resulting in a prompt drop in BP.

I disconnected it from my manifold and ran in neo as I talked to the pharmacist who was sure it was as labeled "Norepinephrine 8 mg/250 cc" but when she checked her counts, she noted that her norepinephrine count was one over the written count and her nicardipine count was one under. She later revealed that she had a new pharmacy intern working with her that was helping her to prepare drips on a very busy day with all 24 OR's running.

Moral of the story is that if something doesn't feel right, trust your instincts and make a change.

That being said, that has been the only error I can recall in the last 5 years and it did nothing to shake my faith in our pharmacy departments.

 

[VentdependenT]

Putting a patient on Levophed doesn't always mean you are headed down the crapper. It is very useful with OPCABG's during bizarre positioning and the patients' do not develop tolerance to it as with neo.

Again, with OPCABG's, dobutamine is a good choice for inotropic support as the patients tend not to have a severe increase in HR, due to preop beta blockade, and the impact on SVR is minimal compared to milrinone.

I agree that having the OR pharmacy premake your infusions is a good idea but mistakes still happen:

Two months ago, I requested my standard OPCAB meds including norepi 8 mg/250cc. During the case I was having a tough time maintaining BP going as high as 8 mcg/min on the norepi. I shut off my Precedex, minimized volatile to a just at 1 MAC with the PSA showing patient adequately anesthetized, and still had problems although the patient responded promptly to 100 mcg boluses of neo. My final test was to draw 2 cc's from my norepi bag and give it IV push, resulting in a prompt drop in BP.

I disconnected it from my manifold and ran in neo as I talked to the pharmacist who was sure it was as labeled "Norepinephrine 8 mg/250 cc" but when she checked her counts, she noted that her norepinephrine count was one over the written count and her nicardipine count was one under. She later revealed that she had a new pharmacy intern working with her that was helping her to prepare drips on a very busy day with all 24 OR's running.

Moral of the story is that if something doesn't feel right, trust your instincts and make a change.

That being said, that has been the only error I can recall in the last 5 years and it did nothing to shake my faith in our pharmacy departments.

Nice catch friggen sherlock holmes.

Most of the time I use levo bad stuff is happening...but then again, I've never done an off-pump CABG.

Only time I use dobutamine is during pediatric hearts (ughhh...painful) and unit patients in decompensated/acute CHF in addition to a medley of pressors.

 

[urge]

My chief resident when I was a CA1 prepared an "8mcg/ml" 250 with 0.2ml of Epi 10cc ampuject(1 mg epi/10cc). Of course pt did not "respond" to epi and required levophed. She basically mixed 200 mcg of epi in 250 instead of 2mg epi, resulting in 10 times underdose.

Chief residents are not necessarily the smartest of the batch. They usually have a good front, though.

 

[VentdependenT]

My chief resident when I was a CA1 prepared an "8mcg/ml" 250 with 0.2ml of Epi 10cc ampuject(1 mg epi/10cc). Of course pt did not "respond" to epi and required levophed. She basically mixed 200 mcg of epi in 250 instead of 2mg epi, resulting in 10 times underdose.

Chief residents are not necessarily the smartest of the batch. They usually have a good front, though.

Dude, I cant wait to see you in action one day....

 

[urge]

Dude, I cant wait to see you in action one day....

You could have. I would have been one of your cardiac attendings. But, I turned Loyola down. I really liked the place but it didn't have the case mix I was looking for. Long story. I might look into it later.

 

[UTSouthwestern]

Nice catch friggen sherlock holmes.

Most of the time I use levo bad stuff is happening...but then again, I've never done an off-pump CABG.

Only time I use dobutamine is during pediatric hearts (ughhh...painful) and unit patients in decompensated/acute CHF in addition to a medley of pressors.

Never done an OPCAB? Yowser. It's a fun ride. Big reason why you get 5 more base points for an OPCAB versus on CAB.

 

[VentdependenT]

You could have. I would have been one of your cardiac attendings. But, I turned Loyola down. I really liked the place but it didn't have the case mix I was looking for. Long story. I might look into it later.

My loss

 

[Arch Guillotti]

Never done an OPCAB? Yowser. It's a fun ride. Big reason why you get 5 more base points for an OPCAB versus on CAB.

My experience w/OPCAB's is that they seemd like a crappy labor epidural, just wanted to gimp through the case off pump till the work was done.

 

[UTSouthwestern]

My experience w/OPCAB's is that they seemd like a crappy labor epidural, just wanted to gimp through the case off pump till the work was done.

It can be that way the first couple of times, but when you know what to expect and when to expect it (i.e. sudden profound hypotension when they place posterior pericardial restraining sutures, et al.) it becomes more predictable and less strenuous.

It does, however, make most other cases a lot easier to handle if you can routinely handle OPCAB's especially with slow surgeons.

 

[Arch Guillotti]

It can be that way the first couple of times, but when you know what to expect and when to expect it (i.e. sudden profound hypotension when they place posterior pericardial restraining sutures, et al.) it becomes more predictable and less strenuous.

It does, however, make most other cases a lot easier to handle if you can routinely handle OPCAB's especially with slow surgeons.

It's been a while since I have done one, but I just remember wanting the case to be over ASAP. BP constantly in the toilet, slow surgeons, etc.

 

[zippy2u]

Burn this formula into your brain: X mgs/250ml = X mikes/min at an infusion rate of 15/hr or 15drops/min. Always use the 250ml bag. Say ya got a 70 kg guy and want to begin a dopamine infusion at 5mikes/kg/min. Throw 350 mgs of the dopamine in the 250 cc bag and run it at 15cc/hr will give ya 350mikes/min. Divide by 70kgs and your at 5mikes/kg/min. 10mikes/kg/min will be infusing if you're at 30cc/hr. Blow off the pharmacy and when ya dump the pt. off in the unit, who cares if they throw away your drips, you didn't pay for the drugs. Regards, ----Zip