Epi Spritzers

[Julius Seizure]

Just wondering how many of your have ever heard of epi spritzers, and how many of your hospitals use them.

I would have posted in a pediatric forum, but I was curious if it was an adult medicine thing as well. So, if you use them - do you work peds or adults?

For those who haven't heard of them, an epi spritzer is where you take 1 code dose of epi and dilute it with NS to a total volume of 10 ml. You would them give 1 ml at a time (1/10th of a code dose).

It would be used for a patient who was becoming hemodynamically unstable, but who you didn't want to slam with a full code dose.

[JKL33]

Controversy! The ED physicians are aware of it, for sure. They get push-back from non-physician camps (namely pharmacy and nursing) with the tone "they just want to try something they read on some website." Unfortunate.

Push-dose pressors for immediate blood pressure control

EMCrit Podcast 6 - Push-Dose Pressors

[Triddin]

We do it sometimes in pre code situations.

[offlabel]

Push dose pressors/inotropes are routine in the operating room, but they are temporizing measures until definitive treatment is in place, ie, appropriate volume resuscitation or continuous infusion of a pressor/inotrope. If folks think they're fixing a problem with "PDP's", then it is controversial and misguided.

It really isn't a big deal.

[JKL33]

Push dose pressors/inotropes are routine in the operating room, but they are temporizing measures until definitive treatment is in place, ie, appropriate volume resuscitation or continuous infusion of a pressor/inotrope. If folks think they're fixing a problem with "PDP's", then it is controversial and misguided.

It really isn't a big deal.

Agree it isn't a big deal. But I've never actually run into a provider who even remotely thinks this is permanently fixing anything, and that idea has had nothing to do with it becoming controversial in newer areas as the concept moves into practice areas where it isn't widely well-established, like the ED. More commonly controversy is caused by things like "nurses and physicians/providers can't compound medications" or even simply, "we've never done that in this area [so it must be wrong]"

[offlabel]

Agree it isn't a big deal. But I've never actually run into a provider who even remotely thinks this is permanently fixing anything, and that idea has had nothing to do with it becoming controversial in newer areas as the concept moves into practice areas where it isn't widely well-established, like the ED. More commonly controversy is caused by things like "nurses and physicians/providers can't compound medications" or even simply, "we've never done that in this area [so it must be wrong]"

Then you'd be surprised how many people give bolus after bolus of a pressor without doing anything else to "permanently" fix something. It becomes controversial when someone makes the blood pressure more align with what he likes and then stops thinking. Happens all the time. That you don't have experience with it doesn't make it a non issue. There is more to this than what the pharmacy or nursing thinks . They have even less experience with it.

[JKL33]

Uh, offlabel, I simply wanted to register the fact that push-back has been observed for reasons other than inappropriate use. I made no such claim that inappropriate use doesn't exist. I said I have not witnessed it, and that inappropriate use hasn't been commonly cited as the particular cause for concern in my area, but that the other types of things I mentioned have been more commonly voiced than concerns of inappropriate use. That is all.

If I had the chance to be perfect, I would've said "does not appear to be the main concern I have heard in my area" rather than "has nothing to do with."

Okay?

Thanks.

[Guest219794]

Adult ER here.

Dirty Epi-

I have seen one drip, and 1 push. The math is easy.

For a drip, 1 mg, which could be either concentration, into 1 ltr ns = 1 mcg/ml. Obviously if you wanted precision, you would have to withdraw either 1 or 10 ml ns prior to adding epi, But, if you wanted precision, you wouldn't be doing some wild west cowboy ****.

Done right, it is a fast way to maintain adequate MAP. Done wrong......

[Julius Seizure]

Adult ER here.

Dirty Epi-

I have seen one drip, and 1 push. The math is easy.

For a drip, 1 mg, which could be either concentration, into 1 ltr ns = 1 mcg/ml. Obviously if you wanted precision, you would have to withdraw either 1 or 10 ml ns prior to adding epi, But, if you wanted precision, you wouldn't be doing some wild west cowboy ****.

Done right, it is a fast way to maintain adequate MAP. Done wrong......

Dirty epi? Like when you add olive juice?

[Swellz]

Dirty epi? Like when you add olive juice?

Epi Spritzer and Dirty Epi are going to be great cocktail names when I start my hospital-themed bar

[ruby_jane, BSN, RN]

I learned a new thing, Julius. Thank you. Also I will see if my local happy hour will make me a dirty Epi Spritzer.

[adventure_rn, MSN, NP]

I'm not sure if this is what you're describing, but my PICU stocks both 'low-dose epi' and 'code-dose epi,' which are different concentrations. It's kind of like what you've described, but pre-diluted (as an aside, hand-diluting epi during an emergency situation seems like a med error waiting to happen). When we have critical patients or post-ops, we're required to have both 'low-dose' and 'code-dose' epi drawn up at the bedside.

We use 'low-dose epi' boluses all of the time when kids start going south to try to prevent codes. At low doses, epi is an inotrope and it actually decreases afterload by lowering systemic vascular resistance. In contrast, code dose epi causes profound vasoconstriction and increased systemic vascular resistance, which shunts a bunch of blood to your coronaries (hence why we use it in CPR), but it also forces your heart to pump harder since it's working against a significantly increased afterload. Basically, low dose epi and high dose epi do very different things. Low-dose provides inotropic support if you're trying to prevent arrest, whereas high-dose improves coronary perfusion after arrest has already occurred (one of the main goals of CPR). We start kids on epi drips at tiny doses to get the 'low-dose' benefits (inotropic effects and decreased afterload), and we stop increasing the dose once they start to have 'high-dose' side effects (vasoconstriction and increased afterload).

In a kid with a sick heart, jumping the gun and giving them 'code epi' before they code might actually cause them to arrest since their hearts can't compensate to overcome the increased systemic vascular resistance, whereas 'low-dose epi' could prevent an arrest by providing intropic and chronotropic support.