mixing meds?

nothing gets mixed with a diprovan drip in our unit. why not just push the etomidate on its own and after a flush use the diprovan. why take a chance when there's no reason to?

Im with you.

My understanding is nothing is mixed with lipid based meds like diprivan.

Is there any reason for this?

I have not had any clinical experience yet, but I am just starting to learn about these drugs. From a very novice point of view, I don't see why you would want to mix two sedative drugs like propofol and etomidate, when they are indicated for different reasons, but work via the same mechanism (GABA receptor). It seems to me you would be losing the benefits of both drugs and gaining the negatives. Like one of the main benefits of etomidate is that is has minimal cardiovascular effects, while propofol can bottom out your BP. Give both together and wouldn't you lose that CV stability of etomidate? Etomidate has side effects like myoclonic movements in up to 1/3 of pts. and adrenocortical suppression, if the pt. CV condition didn't necessitate etomidate, then why add it into propofol and invite these side effects?

Ok a couple of questions then.

How does etomidate hang around exactly? I know it works fast, less than a minute and its effects can wear off as soon as 3-5 min (depending on the text you read). I assume you meant the 75 min half life? In anycase, it appears it could be considered contraversial to be using diprivan and etomidate togeather as research seems to suggest each can potentiate the others hypotensive effects.

One concern I see is how etomidate can block the adrenal gland's production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure. This could lead to abnormal salt and water balance, lowered blood pressure, and, ultimately, shock. The fact that this can last up to 8 hours is a serious consideration and studies seems to suggest that they remain unresponsive to adrenocorticotropic hormone (ACTH) tx for that time. Depending on co-morbities, this is a serious issue.

When i think about diprivan and long term sedation im concerned about oppertunistic bacteria loving that emulsion base. Secondly, the tissue uptake of the drug can be severe after a 5-0 day period slowing recovery for sure. As for use intitially, im not sure that etomidate would not be used but i dont think you would be wise to mix them in one syringe at all. Secondly the doses would have to be carefully adjusted to account for the synergy between the two.

Interesting stuff!

I have never mixed etomidate with anything, but we routinely mix either alfentanil or remifentanil in a 50cc syringe with propofol. The prop-alfenta mix works well for outpatient stuff, especially plastics. I have used the prop-remi mix for thyroids and parathyroids. If you want the little recipe I use, let me know.

The problem with mixing things like this is that the the syringe is prob going to look like a stick of propofol to any other person that walks up. If that person doesnt read to label that hopefully this guy puts he may dose it like it is only propofol and either harm or not adequatly treat the pt.

Now mixing say glycopyrolate and neostigmine I can see as long as you label it b/c giving the Neo b/f the glyco can be detrimental causing bradycardia and bronchospasm and severe issues. So It makes sense to mix these to actually thwart a potential adverse event.

If the practitioner wants to give both than fine but mixing them and leaving them hanging around can only increase the incidence of error. Especially is that CRNA is relieved by someone else and there is a syringe or bag full of this cocktail just hanging around.

Would also think that the mixture could increase infection incidence in the cocktail in the already infection prone propofol.

Either ways do whats best for the pt. I def. know that mixing agents like that is not standard of care and if just once you or someone else harmed a pt with the mixture whether by carelessness or someone not realizing they were giving both that some expert witness would testify saying the mixture expecially in a bag was inappropriate. Hey if you want to use both for an infusion why not just use a 2 channel pump and piggy back one into the other at least so you could know exactly how much you were giving of each at all times. As well just bolus them separately so you can know exactly how much you are giving each time for documentation. I would think since the propofol is lipid based that the etomidate would maybe settle toward one portion of the syringe and if you dont mix it b/f bolus one or the other may be coming out more at first. either ways why set yourself of someone else up for an adverse event when it is totally not needed to administer the drugs like that. My attendings freq tell me many times its the short cuts used to increase efficiency that can come around and bite you in the a$$ when you arent expecting it. Gotta play it safe sometimes in my book.

OMG. White Lightning is awesome. 50mg Special K in 200 mg Prop.

Before you knock it, you might try it sometime.