Meds where infusion rate matters

[ljc]

Anyone have a list of meds where the infusion rate actually matters, preferably with the consequences of infusing too quickly? It seems like every med in the world is listed as "infuse over X minutes", which I know is mostly for nurses, but it would be nice to have a list for the ones that it actually matters.

To start:
Vancomycin - Histamine release, red man syndrome
Protamine - Histamine release, protamine reactions
Dexamethasone - Perineal burning, if awake


What about others? TXA? Calcium? Various antibiotics?

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[vector2]

Amiodarone
Magnesium

 

[DocVapor]

Most important infusion rate is my caffeine intake in the morning.

 

[ambiturner]

Phenytoin, if you ever use it
You can get away with pushing clindamycin but every now and then you’ll get transient hypotension

 

[Bryan O’Blivion]

KCl.

 

[GassYous]

gent

 

[neutro]

Propofol 😃😃

 

[gunnershow]

Metoclopramide

 

[pgg]

Exsqueeze me?

Maybe he means it shouldn't be given at any rate, because it's not a drug that's useful for anything.

 

[pgg]

Phenytoin, if you ever use it

Phenytoin is funny, it should go in by itself in its own IV. It'll precipitate and turn the IV tubing into concrete when mixed with lots of other drugs. Mostly acidic ones, IIRC.

 

[gunnershow]

Exsqueeze me?

Slamming in metoclopramide into awake patients is a recipe for acute dystonic reactions. Have seen it in PACU and C/S rooms.

 

[vector2]

KCl.

I slam potassium in not infrequently (in healthyish pt, no CKD, good peripheral IV) with no issue. Under anesthesia and watching a realtime EKG it's no big. The infusion rate issue with KCl is for floor nurses in q4h vitals, non-anesthetized pts

 

[Bryan O’Blivion]

I slam potassium in not infrequently (in healthyish pt, no CKD, good peripheral IV) with no issue. Under anesthesia and watching a realtime EKG it's no big. The infusion rate issue with KCl is for floor nurses in q4h vitals, non-anesthetized pts

That’s funny, I was going to remark about your magnesium comment that I’ve run 6g into a seizing ecclamptic in about 5 minutes and the only changes I noticed were for the better, some PR lengthening, but ok. Did not have significant hypotension. Generally I’d give mag over 15 minutes, or more. In residency I had an attending who would free run KCl into patients, watching the ECG, so I recognize the truth of what you say, but I feel it’s unnecessarily risky, and would urge caution to most people. From your posts, you are clearly a very knowledgeable clinician, but I wouldn’t dismiss a timed KCl infusion as just for floor nurses. It’s interesting that we have opposite perspectives on these two medications.

 

[UscGhost]

If you are in Texas...

Bupivicaine IV infusions are all the rage right now...so probably slow infusion?

 

[vector2]

That’s funny, I was going to remark about your magnesium comment that I’ve run 6g into a seizing ecclamptic in about 5 minutes and the only changes I noticed were for the better, some PR lengthening, but ok. Did not have significant hypotension. Generally I’d give mag over 15 minutes, or more. In residency I had an attending who would free run KCl into patients, watching the ECG, so I recognize the truth of what you say, but I feel it’s unnecessarily risky, and would urge caution to most people. From your posts, you are clearly a very knowledgeable clinician, but I wouldn’t dismiss a timed KCl infusion as just for floor nurses. It’s interesting that we have opposite perspectives on these two medications.

Yeah I should've clarified that when I said amio and mag I meant "don't IV push X med" since both those meds come in concentrated vials....however op specifically asked if "infusion rate matters."

I agree with you that running in a few gms of mag over a few minutes in an eclamptic pt is fine. Just like I think running in 20 meq KCl over a few minutes while watching the EKG is fine. Drawing up 2gms of mag (or 150 mg of amio or 20meq of K if it hypothetically came concentrated) in a syringe and straight IV pushing it isn't.

 

[anaesthetic]

Yeah I should've clarified that when I said amio and mag I meant "don't IV push X med" since both those meds come in concentrated vials....however op specifically asked if "infusion rate matters."

I agree with you that running in a few gms of mag over a few minutes in an eclamptic pt is fine. Just like I think running in 20 meq KCl over a few minutes while watching the EKG is fine. Drawing up 2gms of mag (or 150 mg of amio or 20meq of K if it hypothetically came concentrated) in a syringe and straight IV pushing it isn't.

I’ve pushed 2 gms of mag IV for a few years now on a lot of cardiac patients coming off of CPB. Zero issues. Have also pushed amio 150 mg IV pretty quickly for bad, hemodynamically significant arrhythmias (not all at once but pretty fast). It’s gone fine. I run potassium on a microdripper.

Doesn’t mean something bad can’t happen, but anecdotally, it’s been okay.

 

[deleted875186]

You can push amio bolus.

 

[vector2]

I’ve pushed 2 gms of mag IV for a few years now on a lot of cardiac patients coming off of CPB. Zero issues. Have also pushed amio 150 mg IV pretty quickly for bad, hemodynamically significant arrhythmias (not all at once but pretty fast). It’s gone fine. I run potassium on a microdripper.

Doesn’t mean something bad can’t happen, but anecdotally, it’s been okay.

You can push amio bolus.

Last time I "pushed' amio (other than a code) was when I gave the perfusionist 150 of amio to drop in the reservoir before coming off and the MAP went to 35-40 for a couple minutes despite some big slugs of levo and vaso (eventually recovered).

But I also have given 150 a bunch of times just diluted in 10 or 20cc syringe which if give over a couple min and it's been mostly fine. I have noticed though when I'm impatient and give too much out of the stick at once the pressure does drop.

Question.....when you push mag, are you giving it after you're totally off pump or while still on full/partial bypass during weaning?

 

[narcusprince]

If you are in Texas...

Bupivicaine IV infusions are all the rage right now...so probably slow infusion?

Too soon, wait this is definitely not funny. People were killed by a madman.

 

[abolt18]

Last time I "pushed' amio (other than a code) was when I gave the perfusionist 150 of amio to drop in the reservoir before coming off and the MAP went to 35-40 for a couple minutes despite some big slugs of levo and vaso (eventually recovered).

But I also have given 150 a bunch of times just diluted in 10 or 20cc syringe which if give over a couple min and it's been mostly fine. I have noticed though when I'm impatient and give too much out of the stick at once the pressure does drop.

Question.....when you push mag, are you giving it after you're totally off pump or while still on full/partial bypass during weaning?

"In the acute setting, amiodarone can cause hypotension due to vasodilation and depression of myocardial contractility; this may be partly due to the solvent, polysorbate 80 or benzyl alcohol, used to assist in dissolving the drug [6–8]. Experimental studies with administration of amiodarone with a relatively non-toxic co-solvent such as cyclodextrin instead of polysorbate 80 and benzyl alcohol is known to be devoid of myocardial depressant effect [9]"

Amiodarone-Induced Life-Threatening Refractory Hypotension

Patient: Male, 70Final Diagnosis: Cardiogenic shockSymptoms: Chest discomfort and intermittent palpitationsMedication: AmiodaroneClinical Procedure: IntubationSpecialty: CardiologyUnusual clinical courseAmiodarone is frequently used in emergency departments ...

www.ncbi.nlm.nih.gov

 

[Beeftenderloin]

Yeah I should've clarified that when I said amio and mag I meant "don't IV push X med" since both those meds come in concentrated vials....however op specifically asked if "infusion rate matters."

I agree with you that running in a few gms of mag over a few minutes in an eclamptic pt is fine. Just like I think running in 20 meq KCl over a few minutes while watching the EKG is fine. Drawing up 2gms of mag (or 150 mg of amio or 20meq of K if it hypothetically came concentrated) in a syringe and straight IV pushing it isn't.

"In the acute setting, amiodarone can cause hypotension due to vasodilation and depression of myocardial contractility; this may be partly due to the solvent, polysorbate 80 or benzyl alcohol, used to assist in dissolving the drug [6–8]. Experimental studies with administration of amiodarone with a relatively non-toxic co-solvent such as cyclodextrin instead of polysorbate 80 and benzyl alcohol is known to be devoid of myocardial depressant effect [9]"

Amiodarone-Induced Life-Threatening Refractory Hypotension

Patient: Male, 70Final Diagnosis: Cardiogenic shockSymptoms: Chest discomfort and intermittent palpitationsMedication: AmiodaroneClinical Procedure: IntubationSpecialty: CardiologyUnusual clinical courseAmiodarone is frequently used in emergency departments ...

www.ncbi.nlm.nih.gov

I’ve done this with Mg and Amio, many times. The Mg I’ll dilute 2g in 4-5 ml, push 1cc at a time every minute or 2. Amio same deal, dilute in 5-10 ml, push 1-2cc at a time, chase with a little presser du jour if needed. Have done it with undilute amio as well 150mg/3ml. I’ve see a worse BP response from protamine and I push that much more frequently.

KCL I’ll free run in, much faster than nursing protocol but still probably over at least 20-30 min for 20meq, keeping a close eye on EKG.

 

[anaesthetic]

Last time I "pushed' amio (other than a code) was when I gave the perfusionist 150 of amio to drop in the reservoir before coming off and the MAP went to 35-40 for a couple minutes despite some big slugs of levo and vaso (eventually recovered).

But I also have given 150 a bunch of times just diluted in 10 or 20cc syringe which if give over a couple min and it's been mostly fine. I have noticed though when I'm impatient and give too much out of the stick at once the pressure does drop.

Question.....when you push mag, are you giving it after you're totally off pump or while still on full/partial bypass during weaning?

Yep, usually will give amio over 2-3 minutes, but I rarely dilute the bolus since I usually try to get at least a bit of the 3 ml in ASAP. I dilute the syringe as I go. Works pretty well.

I usually give the mag when the clamp comes off and almost ready to wean, theoretical benefit of arrhythmia and reperfusion injury prevention, but we also have mag in our cardioplegia solution so I’ve given it less often. It’s a relatively safe drug IMO. Haven’t had noticeable blood pressure swings either way, but who knows? We don’t routinely check mag levels here, so it’s voodoo magic at this point for me.

 

[Beeftenderloin]

Anyone have a list of meds where the infusion rate actually matters, preferably with the consequences of infusing too quickly? It seems like every med in the world is listed as "infuse over X minutes", which I know is mostly for nurses, but it would be nice to have a list for the ones that it actually matters.

To start:
Vancomycin - Histamine release, red man syndrome
Protamine - Histamine release, protamine reactions
Dexamethasone - Perineal burning, if awake


What about others? TXA? Calcium? Various antibiotics?

I push TXA or just run the 100cc bag to gravity all the time. Everyone has either received some sort of GABA agonist (midaz, prop), or is under GA (which is literally the end of the algorithm for status epilepticus). Have never seen anyone seize. I recognize non-convulsive status is also a thing, I just don’t think 1g of TXA with some GABA agonist on board is enough to tip them into a seizure. They’d have to have a known poorly controlled seizure disorder and/or have been off their meds to give me pause.

 

[agammaglobulin]

Good thread.

I push TXA for total joints frequently. I did it once when the patient wasn't all the way asleep and they started complaining of strange symptoms... Lesson learned. Never had problems once the patient is asleep. Like @Beeftenderloin said above, med is frequently given after patient has received some versed and while propofol is running in for TKA/THA case, so I'm not too concerned about seizures.

Levofloxacin - hypotension. Have been burned by this when giving it quickly during/after induction before procedure start resulting in BP drop.
Azithromycin - Anecdotally, when given to C/S patients quickly they seem to get nauseous. Slowing the rate down seems to help.

 

[propadope]

Precedex-hypertension, brady, hypotension

 

[jwk]

Anyone have a list of meds where the infusion rate actually matters, preferably with the consequences of infusing too quickly? It seems like every med in the world is listed as "infuse over X minutes", which I know is mostly for nurses, but it would be nice to have a list for the ones that it actually matters.

To start:
Vancomycin - Histamine release, red man syndrome
Protamine - Histamine release, protamine reactions
Dexamethasone - Perineal burning, if awake


What about others? TXA? Calcium? Various antibiotics?

There's very few drugs outside the cardiac OR where the actual rate is really important. If I don't need to know an actual rate of infusion (mcg/kg/min or whatever) and just don't want to run something in too fast, we either push it slowly or use a dial a flow device, or just slow down the drip rate on a regular infusion or secondary set. I had a pt the other day where the hospitalist ordered KCL 10meq. Of course it was on a pump set to run in over 2 hours. The nurses had a fit when I took it off the pump to go to the OR.

 

[nimbus]

Many practices that are unsafe or consequential for awake, unattended, and unmonitored patients on the floor are safe and inconsequential for anesthetized and continuously monitored patients in the OR. The setting makes a big difference. The same rules should not be generalized to all locations.

Vecuronium is dangerous for spontaneously breathing patients in a CT scanner but not in other settings.


On the floor they give 1unit of packed cells over 3 hours but in the OR it sometimes has to be less than 5min.

 

[drmwvr]

DDAVP

 

[ljc]

There's very few drugs outside the cardiac OR where the actual rate is really important. If I don't need to know an actual rate of infusion (mcg/kg/min or whatever) and just don't want to run something in too fast, we either push it slowly or use a dial a flow device, or just slow down the drip rate on a regular infusion or secondary set. I had a pt the other day where the hospitalist ordered KCL 10meq. Of course it was on a pump set to run in over 2 hours. The nurses had a fit when I took it off the pump to go to the OR.

This brings up a question I've had: Just how much KCl would you have to PUSH to run the risk of EKG changes/arrest? Obviously the veins don't like it, but pretend you have a central line and this is less of a concern (although that brings up another question -- do we ever worry about how "caustic" the meds are to the central veins?)

It's one I've wondered about frequently but always been too afraid to try for myself. Will pushing a load of 10meq or 20meq KCl rapidly risk arrest?

And I similarly will hang things on secondary sets or just flush it into an IVF bag and run that in, but I'm more curious about what meds will actually cause adverse outcomes if pushed quickly. So when you say you "don't want to run something in too fast", are you actually worried about a bad outcome?

 

[ljc]

Many practices that are unsafe or consequential for awake, unattended, and unmonitored patients on the floor are safe and inconsequential for anesthetized and continuously monitored patients in the OR. The setting makes a big difference. The same rules should not be generalized to all locations.

Vecuronium is dangerous for spontaneously breathing patients in a CT scanner but not in other settings.


On the floor they give 1unit of packed cells over 3 hours but in the OR it sometimes has to be less than 5min.

Mostly this stems from me getting dirty looks from the nurses when I push various meds. Off the top of my head, I can remember getting funny looks/comments when pushing TXA, dexmedetomidine, various antibiotics, etc.
I've never had any clinically meaningful adverse events from any of those, but have no data to support that it's actually safe.

Also agreed about the Vec.

 

[ljc]

I push TXA or just run the 100cc bag to gravity all the time. Everyone has either received some sort of GABA agonist (midaz, prop), or is under GA (which is literally the end of the algorithm for status epilepticus). Have never seen anyone seize. I recognize non-convulsive status is also a thing, I just don’t think 1g of TXA with some GABA agonist on board is enough to tip them into a seizure. They’d have to have a known poorly controlled seizure disorder and/or have been off their meds to give me pause.

This is exactly what I was looking for. Thanks!

What about in OB patients? We give TXA for C/S occasionally. Most of those patients haven't had any midaz/prop. Would you drip it in slowly for them?
I know seizures is the known side effect from TXA, but what's less clear is whether that is from a bolus load to the CNS or whether it has more to do with the long term effects of the meds. There's plenty of data showing increased ICU seizure rates in post-bypass patients who got TXA, and obviously those patients are asleep when they get TXA.

 

[nimbus]

Mostly this stems from me getting dirty looks from the nurses when I push various meds. Off the top of my head, I can remember getting funny looks/comments when pushing TXA, dexmedetomidine, various antibiotics, etc.
I've never had any clinically meaningful adverse events from any of those, but have no data to support that it's actually safe.

Also agreed about the Vec.

One of our new hires got written up by a nurse for pushing propofol through the same line in which blood was infusing (the patient’s only line.). Apparently on the floors, it is a big no-no to push any drugs through an IV that is being used to transfuse.

 

[ljc]

Good thread.

I push TXA for total joints frequently. I did it once when the patient wasn't all the way asleep and they started complaining of strange symptoms... Lesson learned. Never had problems once the patient is asleep. Like @Beeftenderloin said above, med is frequently given after patient has received some versed and while propofol is running in for TKA/THA case, so I'm not too concerned about seizures.

Levofloxacin - hypotension. Have been burned by this when giving it quickly during/after induction before procedure start resulting in BP drop.
Azithromycin - Anecdotally, when given to C/S patients quickly they seem to get nauseous. Slowing the rate down seems to help.

Have definitely noticed the Azithro nausea. The levofloxacin one is new to me. Thanks!

 

[ljc]

One of our new hires got written up by a nurse for pushing propofol through the same line in which blood was infusing. Apparently on the floors, it is a big no-no to push any drugs through a line that is being used to transfuse.

The "compatibility" thing is another question that I had, but wanted to focus on one question at a time. Nurses are very big on compatibility of meds, while for me it barely crosses my mind. Mostly because we push meds so fast while nurses generally use infusions, but still. I've had nurses stop me from giving meds in the ICU before until they could check the compatibility, which is super frustrating.

 

[vector2]

The "compatibility" thing is another question that I had, but wanted to focus on one question at a time. Nurses are very big on compatibility of meds, while for me it barely crosses my mind. Mostly because we push meds so fast while nurses generally use infusions, but still. I've had nurses stop me from giving meds in the ICU before until they could check the compatibility, which is super frustrating.

I love it when I drop a pump case off who has a MAC line, swan, and a PIV, and the first thing the nurses do is complain about lack of access because they can't (won't) use the multiport manifold from the OR with perfectly compatible meds.

 

[nimbus]

I love it when I drop a pump case off who has a MAC line, swan, and a PIV, and the first thing the nurses do is complain about lack of access because they can't (won't) use the multiport manifold from the OR with perfectly compatible meds.

Everything mixes inside the patient

 

[nimbus]

The "compatibility" thing is another question that I had, but wanted to focus on one question at a time. Nurses are very big on compatibility of meds, while for me it barely crosses my mind. Mostly because we push meds so fast while nurses generally use infusions, but still. I've had nurses stop me from giving meds in the ICU before until they could check the compatibility, which is super frustrating.

It’s plausible that compatibility can be a bigger issue if concentrated meds mix and sit inside the IV tubing for hours. But that’s not how we administer drugs.

 

[PpfSuxTube]

Last time I "pushed' amio (other than a code) was when I gave the perfusionist 150 of amio to drop in the reservoir before coming off and the MAP went to 35-40 for a couple minutes despite some big slugs of levo and vaso (eventually recovered).

But I also have given 150 a bunch of times just diluted in 10 or 20cc syringe which if give over a couple min and it's been mostly fine. I have noticed though when I'm impatient and give too much out of the stick at once the pressure does drop.

Question.....when you push mag, are you giving it after you're totally off pump or while still on full/partial bypass during weaning?

I put the 150 of amio into a 30ml syringe and push half, dilute half, push half etc. Its in a minute. Havent seen much hypotension that way...

Every cardiac case gets 2 gm mag where we work. Its comes in 50ml bag, and gets ran in stat mostly...

Ill push protamine up to 70 or 80mg at a time... but with ephedrine, and phenyl chaser

 

[repititionition]

I bolus a gram of mag not infrequently, never had a problem. I’ve never been burned by amio, though that’s always a bit slower in my hands. Serious PPH on OB, I have given 1000 of TXA in under a minute many times without adverse effect. Not saying it can’t happen, merely saying I haven’t seen it yet.

Phenytoin, on the other hand... repect that, both for the cardiotoxic effects and its ability to precipitate (as mentioned above).

 

[abolt18]

Calcium (gluc or chloride) seems to cause some intense sensations of being hot and getting flushed, in the awake patient. I've seen it with both.

 

[Dantrolene FC]

Hmm… I didn’t realize some of these were a thing. On OB, I’ve squeezed the TXA in as fast as it can every time I’ve given it. And in the main OR, I’ll give 2 g of magnesium to gravity routinely.

 

[DrOwnage]

This is why I hate urology cases. 30 minute case. I get one IV with 2 ports and the patient rolls in with a full gent and levaquin bag to be given…

 

[deleted1147063]

This is why I hate urology cases. 30 minute case. I get one IV with 2 ports and the patient rolls in with a full gent and levaquin bag to be given…

Great! Tell them they're going to have to wait till the antibiotic is all in, according to the guidelines.

Then they'll stop doing this to you. With humans, it's all about finding the right incentives.

 

[Beeftenderloin]

I put the 150 of amio into a 30ml syringe and push half, dilute half, push half etc. Its in a minute. Havent seen much hypotension that way...

Every cardiac case gets 2 gm mag where we work. Its comes in 50ml bag, and gets ran in stat mostly...

Ill push protamine up to 70 or 80mg at a time... but with ephedrine, and phenyl chaser

What in the world are you pushing ephedrine (aka levo flavored La Croix) for in a CV case? You’ve got levo hanging. Just pull some off the bag and dilute to push dose.

 

[nimbus]

This is why I hate urology cases. 30 minute case. I get one IV with 2 ports and the patient rolls in with a full gent and levaquin bag to be given…

That’s when the scorpion and the chicken foot are your friends.

 

[pgg]

Calcium (gluc or chloride) seems to cause some intense sensations of being hot and getting flushed, in the awake patient. I've seen it with both.

I've given a bolus of calcium to an awake patient, once. I'll try not to ever do it again.

It provoked some mild chest discomfort in the patient which generated some anxiety. It has a sort of inotrope/contractility augmenting effect so in my mind I imagined it causing an abrupt pounding/thumping heart sensation. Anyway. The patient didn't like it.

 

[Radetzky]

I once slammed 6g of magnesium into an awake patient dying of asthma. He didn’t seem to mind too much. I mean he was probably distracted and also experiencing some CO2 narcosis but importantly it didn’t cause any hemodynamic effects. And I’ve bolused Mg routinely in anesthetized pts without issue

 

[jwk]

I've given a bolus of calcium to an awake patient, once. I'll try not to ever do it again.

It provoked some mild chest discomfort in the patient which generated some anxiety. It has a sort of inotrope/contractility augmenting effect so in my mind I imagined it causing an abrupt pounding/thumping heart sensation. Anyway. The patient didn't like it.

Sounds like my lexiscan stress test - two minutes of suck.

 

[drmwvr]

What in the world are you pushing ephedrine (aka levo flavored La Croix) for in a CV case? You’ve got levo hanging. Just pull some off the bag and dilute to push dose.

IME what is hanging in a heart room is local culture, i.e.... epi and neo, dobutamine and vaso, norepi and...whatever...I don't hang NE routinely in a heart.

 

[Iso4ane]

Most important infusion rate is my caffeine intake in the morning.

I treat it the same as any one drugs...."Five minutes?! How a bout 5 seconds." (Works better with iced coffee).

I once slammed 6g of magnesium into an awake patient dying of asthma. He didn’t seem to mind too much. I mean he was probably distracted and also experiencing some CO2 narcosis but importantly it didn’t cause any hemodynamic effects. And I’ve bolused Mg routinely in anesthetized pts without issue

No hemodynamic effects? Was he already dead? Otherwise, if you dilute and give 2mg over like one minute and not 5 seconds, you'll be fine.