Epinephrine error

[katie4593]

Recently I witnessed a medication error with epinephrine, the patient was a 26 year old female, written for 0.5mg of epinephrine sq due to a allergic reaction to a medication, PT had hives/facial swelling. The patient was given 0.5mg of epinephrine 1:10,000 IV push. The patient for a few moments had sinus tachycardia, shortness of breath, chest pain, decreased vision & the feeling as if they were going to pass out. After a minute or so vitals were back to baseline & the patient only had complaints of a headache. Patient was admitted for observation, troponins/ekg were normal, echocardiogram was normal, also a Mri of the head was done as the patient had continued headache which was negative for any findings. My question is do epinephrine errors happen often? Also, I'm curious how this patient received such a high dose of epi but had no harm done, seems rare.....

[JKL33]

Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared... - PubMed - NCBI

Safety of epinephrine for anaphylaxis in the emergency setting

Anaphylaxis: Emergency treatment

Epinephrine in the treatment of anaphylaxis

https://vanderbiltem.com/images/2017handouts/High-RiskSafeUseofIVandIMEpinephrineHANDOUT.pdf

[Wuzzie]

The OP's example was regarding SQ injection, which is not the preferred recommended route for anaphylaxis, IM is considered an appropriate alternative for IV particularly when given by someone not experienced with epinephrine or the ability to closely monitor the patient (or when there is no IV access). When given at the appropriate rate and with the appropriate monitoring, IV is more predictable and better facilitates avoiding giving an excessive dose.

Appropriate route of administration of epinephrine

Muno, you certainly have generated an interesting and informative discussion which I have appreciated. However, in the scenario given, the nurse did make a medication error. SubQ Epi, while not the current preferred method is still allowable and was ordered. The nurse gave the medication IV which, while not the wrong route per current literature, was still not given as ordered in this situation. Maybe I'm splitting hairs. Had the nurse questioned the order that would have been one thing but she didn't. And she violated one of the 5 (or 6 or 7 or 9 or eleventy billion) rights.

[Boomer MS, RN]

I wish we could all be in room once a month for a group discussion. It would be easier! I need to catch up on the responses and their links but wanted to clarify my response re: SQ epi and the other two drugs given for an allergic reaction. In those numerous situations when the 3-drug cocktail was given, the patients were not having an anaphylactic reaction. For anaphylaxis, of course IV epi would be ordered and given. Having worked at four EDs, I found that what was considered normal and everyday practice at one facility would be forbidden in others. Procedural sedation drugs come to mind.

[RobbiRN, RN]

The error should be easy to avoid: The little vial (1:1000) that you have to break to get into and extract with a syringe is designed for IM. The big one (1:10,000) which is pre-diluted and comes with a lure lock attachment is designed for IV administration.

Interesting and helpful discussion for me anyway -- even though we strayed from the medication error part of the story. Thank you to MunoRN and JKL33 for adding the links. So, summarizing some key points from the links, when using epi to treat anaphylaxis:

1. IM is preferred to SQ.

2. The right thigh site provides a faster increase in blood levels than the upper arm.

3. The turning point for using IV epi is "cardiovascular collapse," or a rapid progression in that direction, due to the potential for adverse effects from the IV route if it is not clinically indicated.

From my experience, IM epi works in minutes. Any IV push can be over one, two or several minutes; it doesn't have to be jammed in over a few seconds -- unless the patient is in cardiovascular collapse or rapidly headed that way. Young healthy hearts can tolerate epi better than old diseased hearts. Evaluate and treat the patient as needed while mitigating risk. Most allergic reactions, even those with mild to moderate angioedema, can be treated with IV benadryl, solumedrol and pepcid. But these patients can decompensate really fast, and they deserve our constant attention until the threat is neutralized.

[Laura_Bailly, BSN]

There is a great podcast, by Dr.Steve Carroll, called EM Basic Podcast. There is an episode on anaphylactic reactions and he covers the concentrations and routes for Epi. I hope this helps.

Anaphylaxis Part 1- Diagnosis and Treatment | EM Basic

[KatieMI, BSN, MSN, RN]

0.5 mg IV dose of Epi is standard EU protocol for SEVERE (anaphylaxis with shock or impending respiratory arrest, NOT just facial edema) allergic reaction with easy IV access. It does cause all the side effects described and sometimes SVT which has to be reversed but in the situation like above it is a small bargain for being alive. The very same side effects are possible (and commonly happen, up and including hypertensive emergency) with SQ administration as well.

When I was in the EU, I could be given Epi either SQ, I'M or IV, depending on how things were looking, and in some countries IV seems to be preferred route. I have baseline low BP, so people get understandably scared when they see someone still speaking with 50/35.

As for right now, when high risk of massive Epi doses for "allergic reactions" of any kind is finally getting recognized (thanks Mulan Pharma and their campaign for promoting Epipen as "safe and effective"), adult patients with high risk of anaphylaxis are re-educated about not shooting a dose every 5 min doesn't matter what and not using Epinephrine for minimal severity reactions. Epinephrine is definitely effective stuff, but it is for no means "safe" one.

According to how we practice medicine in States, IV Epi belongs to ACLS protocols and its IV use is limited. So, yeah, the nurse made a med error. It did not lead to anything too bad except side effects which were expected anyway, but it is still technically med error.

[JKL33]

Just listened to the whole podcast. It covers everything we've been discussing. Thanks so much, Laura.

ETA: I hope others have time to listen, but I'll just mention a couple of things for those who can't right now.

SQ is more than just 'not preferred' - - it won't work b/c the subq layer is not adequately perfused in the setting of anaphylaxis.

IM doses x 3

If not improving after 2nd or 3rd IM dose, move to IV epi, but Dr Carroll has a dilution that he describes thoroughly. He is NOT using 1:10,000, but diluting it even further. There is a lot of other excellent info if you have time to check it out. :)

[akulahawkRN, ADN, RN, EMT-P]

This is a great discussion about epinephrine! From my own training, in the adult population, I would generally use 0.3mg 1:1,000 IM, though 0.5mg would also work quite well. As discussed, IM works much better than SQ, though SQ will actually work. The reason I'd use only the 1:1,000 concentration in an IM or SQ should be quite obvious: volume. It's also the same reason I'd use 1:10,000 in an IV. While the dosage may be the same, it's far easier to control an administration of 0.1mg of 1:10,000 via IV than it is to control 0.1mg 1:1,000. Just try giving 0.1mg of 1:1,000 IV over a couple minutes...

The symptoms reported are exactly what I'd expect to see when 0.5mg is given IV to a conscious patient. There are two situations where I'd give IV epi vs IM epi as discussed here and it's very simple: code and imminent airway/CV loss due to anaphylaxis. Sure, you can use epi as a pressor agent but in those situations you're looking more at a very diluted concentration compared to what we're using to deal with a code or severe anaphylaxis.

Now as to whether or not the nurse in question made an error, the answer is yes, the error was that the medication was given via incorrect route, not as ordered.

One last thing: yes, while the absorption rate is a bit unpredictable with the IM route, it's going to be much slower than IV so you shouldn't see quite the dramatic symptoms though you should see a rapid decrease in anaphylaxis symptoms.

[T-Bird78]

When doing pt education on epipens for my allergy pts I'd explain all these sx and say they were to be expected with epi. I did that mostly to prevent pts from telling me they were allergic to epi because of the tachycardia. I've never given epi SQ, only IM, and working in allergy I gave A LOT of epi. Seems like giving an emergency med SQ defeats the purpose of the emergent situation.

[KatieMI, BSN, MSN, RN]

BTW, Epipen and similar injectors work more IM than SQ. They have pretty long needles designed to go through snow pants if necessary, and the "jab" presses against the fat, delivering the drug deeper. In addition, the power of the spring inflicts quite a trauma (the shots are VERY painful for this very reason; plus, I suspect that developers knew that in shock some sharp pain is, in fact, beneficial).

Epis work even in most severe cases of anaphylaxis despite of circulatory collapse because it is very diluted drug delivered deep in tissues in large myscle/fat area. It absorbs by simple diffusion, and only one thing then needed is "main shock circle" circulation (heart/lungs/brain) being preserved at least to some degree.

And, yeah, people need to be taugh that epinephrine is one of the things a human being just cannot be allergic to. Although, Epi injection is not a piece of cake even under the best circumstances.

[Julius Seizure]

If not improving after 2nd or 3rd IM dose, move to IV epi, but Dr Carroll has a dilution that he describes thoroughly. He is NOT using 1:10,000, but diluting it even further. There is a lot of other excellent info if you have time to check it out. :)

This sounds similar to what I have seen used in "not-quite-code" situations in a few different pediatric ICUs. They call it an "epi spritzer", and its 1 code dose of epi (weight based for peds), diluted with NS to a total volume of 10ml. Therefore, 1 ml = 1/10th of a code dose.

[NavySRNA]

"26 year old female, written for 0.5mg of epinephrine sq due to a allergic reaction to a medication"

The pt was young and healthy, which likely explains why she handled that dose of epi without any major adverse events.

"PT had hives/facial swelling. The patient was given 0.5mg of epinephrine 1:10,000 IV push."

As explained in previous posts, 1:10000 is the concentration of epi. You can look at the concentration another way... epi 1:10000 = 1g/10000ml or 1000mg/10000ml=0.1mg/ml.

Epi 1:1000 = 1g/1000 = 1000mg/1000ml = 1mg/ml. The ordered concentration should be a clue to the route of administration. You probably wouldn't want to give epi 1:10000 SQ or IM since a 0.5mg dose would be a volume of 5ml. The route and dose ordered by the doctor was not unreasonable. He/she probably wanted the slow rate of absorption from SQ administration, since this doesn't sound like a life-threatening anaphylactic reaction. If you have a question about the order, it is not only our right to question it, but our RESPONSIBILITY.

"The patient for a few moments had sinus tachycardia, shortness of breath, chest pain, decreased vision & the feeling as if they were going to pass out. After a minute or so vitals were back to baseline & the patient only had complaints of a headache."

Epi hits alpha 1s and 2s and also beta 1s and 2 receptors, so the symptoms you described are exactly what you would expect. Epi is a sympathomimetic, meaning it mimics the sympathetic nervous system. Alpha 1s are going to give you an increase BP from vasoconstriction, Beta 1s are going to cause tachycardia, and Beta 2s will give you bronchodilation. In the OR we sometimes give epi when other pressors are not working (ephedrine, phenylephrine, vasopressin). When treating hypotension with epi, I'm usually giving IV doses of 10-20mcg (.01-.02mg), and see almost instant increases in BP and HR. I can only imagine how high this patients BP was after receiving 500mcg (0.5mg) of epi. The DOA of epi is around 5 mins, which explains why her symptoms quickly subsided.

"My question is do epinephrine errors happen often?"

Medication errors, unfortunately, are not uncommon. I would suspect that error rates go up with drugs not commonly administered (like epinephrine), but I do not have data to back that up. Some of the medications we give can have serious consequences, which is why we have things like 5 rights of medication administration. If you're giving a medication you haven't used in a while, take the time to look it up, ask a coworker, google it, or call the prescribing provider to clarify. Oh, and remember, we all make mistakes. Fortunately the human body is resilient, and its tough to kill an adult with a medication error.