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.
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.
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What are the concentrations of each? And how are they dosed?
What are the concentrations of each? And how are they dosed?
Great question--it may be a lower concentration than what the OP is describing (i.e. 1:100 instead of 1:10 vs code epi). I can't remember off the top of my head and I can't find examples of what I'm looking for online, but I'll try to text one of my coworkers who is on to find out. The 'low dose epi' dosing is listed first on all of our code sheets and we stock it at every bedside, so it's pretty ubiquitous on my unit.
It's not that often that non-code doses of epi are needed, but when they are I haven't encountered too much resistance. Typically if we need something to immediately reverse acute hypotension while other interventions are put in place, it's usually phenylephrine if it's just severe hypotension, or epi for a patient who's bradying down and severely hypotensive, we use the prefilled epi vials which are 1mg to 10mls, so we usually give 'aliquots' of 1ml at a time (0.1mg).
I haven't found much resistance to giving repeat, small doses of epi in order to avoid a code and to buy time to initiate other therapies. There is certainly some skepticism about the use of epi in full cardiac arrest, particularly out-of-hospital cardiac arrest and unwitnessed inpatient cardiac arrest, since there is little if any evidence that epi improves the potential for a meaningful recovery after cardiac arrest. This is likely due to epi's ability to jolt a return of circulation potentially long after irreversible anoxic brain injury has occurred. But for the purpose of maintaining cerebral perfusion, rather than restoring perfusion to an already severely damaged brain, docs typically don't oppose emergent pushes of pressors or inopressors.
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).
Okaaay adventure, I see you over there with your science knowledge!
Okaaay adventure, I see you over there with your science knowledge!
Lol, I wish. After years of NICU, I started this summer in a peds cardiac ICU and it has been a crash course in all things cardiac. We've already had about 30 classroom hours on peds cardiac in addition to our shifts on the unit, so I'm doing my best to learn what I can. I only know this whole 'high dose vs. low dose epi' phenomenon because our peds cardiac pharmacist covered it in class a few weeks ago, and I'm hoping that explaining it on this forum will help me commit it to memory.
Honest to god, the peds cardiac intensivist NPs, attendings, and fellows are some of the smartest people I've ever met. If I can understand even a fraction of what they know, I feel like I'm moving in the right direction.
Meanwhile, if you guys are serving up epi spritzers in the form of a fine perfume or a mixed drink, this gal wants in!
Great question--it may be a lower concentration than what the OP is describing (i.e. 1:100 instead of 1:10 vs code epi). I can't remember off the top of my head and I can't find examples of what I'm looking for online, but I'll try to text one of my coworkers who is on to find out. The 'low dose epi' dosing is listed first on all of our code sheets and we stock it at every bedside, so it's pretty ubiquitous on my unit.
Just a point of order, 1:100 epi means 10 mg/ml and 1:10 epi means 100 mg/ml. These are concentrations that are not used in clinical practice.
1:1000 is the 1 mg/ml amp for mixing infusions and the standard 1:10,000 bristojet "code" epi is 100 mcg/ml.
So called "pedi" epi is 10 mcg/ml, or 1:100,000 epi.
Just a point of order, 1:100 epi means 10 mg/ml and 1:10 epi means 100 mg/ml. These are concentrations that are not used in clinical practice.
1:1000 is the 1 mg/ml amp for mixing infusions and the standard 1:10,000 bristojet "code" epi is 100 mcg/ml.
So called "pedi" epi is 10 mcg/ml, or 1:100,000 epi.
To add to that, the old "1:10,000" , "1:100" etc concentration has been forbidden since 2016 when ISMP recommended and regulatory bodies followed suit that epinephrine use the standardized dosage labelling all other drugs use which is mass per volume (1mg per 10ml for instance). Packaging can still show the 1:10,000 style measurement but also must include the more correct format of mg or mcg per volume.
Just a point of order, 1:100 epi means 10 mg/ml and 1:10 epi means 100 mg/ml. These are concentrations that are not used in clinical practice.
1:1000 is the 1 mg/ml amp for mixing infusions and the standard 1:10,000 bristojet "code" epi is 100 mcg/ml.
So called "pedi" epi is 10 mcg/ml, or 1:100,000 epi.
I have never heard of "pedi epi". Can you tell me more about how that comes into play at your job? In my world, kids get the usual concentration of epi ("code epi"), but dosed by weight. Its not a different concentration. Sounds like this would get confusing, but I'm sure its not when its just the way your job does it.
I have never heard of "pedi epi". Can you tell me more about how that comes into play at your job? In my world, kids get the usual concentration of epi ("code epi"), but dosed by weight. Its not a different concentration. Sounds like this would get confusing, but I'm sure its not when its just the way your job does it.
Well, "pedi epi" is just a contrived term to distinguish it from commercially prepared epi. And we only use that term when we're taking care of kids. I use the epi right out of the infusion bag for adults for push doses and that is 8 mcgs/cc and I don't call it pedi epi. It's just an institutional culture thing.
Push dose epi where I am, is just for those brief periods of hypotension in anesthesia and surgery that are transient and usually self limiting or treated with volume/blood.
For real little kids that need active pharm resuscitation, I put a stopcock on the 1:10000 commercially prepared syringe with a one cc syringe and dose to weight.
chare
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What are the concentrations of each? And how are they dosed?