Diluting SQ Epi

in the spirit of safe practice - i am going to try to explain this-

it is easy to confuse these 2 concentrations - but the key is to remember how they are used in clinical practice. epinephrine is most always a 1mg dose - it just varies with the dilution.

1 mg in 1 ml is always used as a sq medication. it is almost always in a single ml vial, ampoule. this is called 1:1 or 1:1000.

1 mg in 10 ml (of ns) is usually a pre-filled syringe in a boxed container and is given in patient situations that require resuscitation. it is never given except in critical patient situations. this is called 1:10 or 1:10,000.

i think it is more accurate to call it 1:1 (the sq dose) or 1:10 (the resuscitation dose). it just makes it confusing - and these are some who delight in confusion.

subcut or sq - epinephrine is always given as a dose strength of:

1 mg (milligram) in 1 ml.

this is commonly called 1:1 epi or 1:1000 epi. i know it can be confusing. this dose is most commonly found in 1 ml vials or rarely in 30 ml multi-use vials. i have never seen this dose in pre-filled syringes.

but the bottom line: look at the medication - it should note 1 mg in 1 ml.

this dose strength is never diluted for administration.

a typical dose of epi given this was is usually:

0.3 mg and will be 0.3 ml

* (sometimes it may be 0.1 mg/0.1 ml or as much as 0.5 mg/0.5 ml in a single dose)

so, what does this mean? to give subq epi 1:1 you give the portion of the ml that corresponds to the dose. each 0.1 ml or 1/10 of the ml is equal to 0.1 mg or 1/10 of a milligram

use a 1 ml syringe.

always make it easy on yourself. use the most accurate syringe for the medication/route that you have available. i find that when giving partial amounts of a single ml - i always find it easier/more accurate to use a small syringe. draw up the ordered amount of medication.

(don't even try to administer with a 3 ml syringe - it just gets too confusing! - and can decrease your accuracy!)

do not attempt to dilute this and make it complicated.

this is simple medication administration.

after all you do not want to inject a large quantity (fluid) as sq administration. imagine injecting 3 ml as a sq injection. ewwww!

.......... .......... .......... ..........

so good rules for med administration that can save you from disaster:

if it takes multiple dilutions, large numbers of vials, unusual amounts to administer (meaning 5 ml as a sq injection - or 40 ml as an iv push) the ordered dose - it is always a good idea to stop.

at this point.

* clarify the order.

* the 5 rights! right now!

so, the short answer is you do not dilute epi for sq administration.

but, rather than just noting that - i though it may be useful to know why/how. i hope this was helpful (and not too confusing).

practice safe!

NREMT. Excellent answer!

I have worked at places where all you had was 30 ML 1:1,000 multidose vials and were required to make your own 1:10,000 concentration for IV use. I agree, that you should pay close attention to this medication. I know of people who have given incorrect doses and concentrations of this medication with less than desirable outcomes.

I quick note on S/Q vs IM during anaphylaxis:

"Recent data have come to light regarding the preferred method of administering epinephrine. Simons et al performed a study in children in which they reported that IM injection of epinephrine is superior to subcutaneous administration.[35] This conclusion was based in delayed epinephrine absorption with subcutaneous compared with IM administration. The difference was hypothesized to be due to the cutaneous vasoconstrictive properties of epinephrine. They extended their findings to adults and further defined that IM injection into the thigh (vastus lateralis) is preferred to IM injection into the deltoid.[36] This conclusion is based on the superior serum levels of epinephrine achieved by this method in comparison to subcutaneous injection as well as IM injection into the deltoid. Superiority of blood flow to the vastus lateralis is hypothesized to account for this difference.[36]"

http://www.medscape.com/viewarticle/497498_8

I have worked at places where all you had was 30 ML 1:1,000 multidose vials and were required to make your own 1:10,000 concentration for IV use. I agree, that you should pay close attention to this medication. I know of people who have given incorrect doses and concentrations of this medication with less than desirable outcomes.

So during a code you had to sit & mix up your own IV epi??? No pre-filled syringes??? Kind of a time-waster in a code situation, don't you think? Every place I've worked at has the little glass 1ml ampules for SQ & the pre-filled syringes for IV.

That is correct we mix our own 1;10,000. No prefilled syringes of 1:10,000.

That is correct we mix our own 1;10,000. No prefilled syringes of 1:10,000.

i'm just curious how that works out in a code..do you just have someone mixing away and waste what you don't end up using? Seems like having to stop and mix truly does delay everything.

I agree with using the small syringes for SQ epi. I always use the 1CC syringe..it really does make it ALOT easier and also quicker to get the med to bedside. If you are to the point of using epi, you are typically not going to have time to stop and try to figure out the dosage on even a 3cc syringe.

BTW, phiposurde, I really enjoyed the information you posted regarding SQ vs IM epi. I haven't heard of that study and thought it was very interesting. Thank you!

I think this was done because it saves space. The 1:1000 vials are used by a flight service. I guess having only 1 vial saves space over several 1:10,000 containers. We do waste what is not used. I am not sure about delays, I sit next to the meds and mixing the epi is no more time consuming than tearing the box apart and screwing the componets of the 1:10,000 container together. I agree that in a stressful situation the potential for error is higher

Short version - EPI 1mg - diulte in 9ml of sodium chloride 0.9% - that is equivilant to 1mg/10ml emergency syringe

I quick note on S/Q vs IM during anaphylaxis:

"Recent data have come to light regarding the preferred method of administering epinephrine. Simons et al performed a study in children in which they reported that IM injection of epinephrine is superior to subcutaneous administration.[35] (...snip...)

Interesting. I'm going to forward that medscape article to our medical director. Thanks for the link.