Epinephrine Drips

rstewart · Sep 18, 2003

Epi drips are usually mixed using 1mg 1:1000 (1 ml) in 250 0r 500 cc fluid which yields concentrations of 4MCG/ml or 2MCG/ml. Start at 1-2 MCG/min----usual range is 2-10 MCG/min.

Now pleaaaaaaaaaaase don't flame me but.....I am somewhat surprised that a CCRN working in an ICU does not know that basic information off the top of his/her head.

This is in no way a reflection on you personally------but it just confirms in my mind what a joke ACLS etc. has become. We are just not doing a good enough job teaching vital information anymore---at least for those nurses who might be expected to run a code in their practice environment.

Zee_RN, BSN, RN · Sep 18, 2003

I won't flame you.

But I've NEVER used an epi drip. How am I to know it? I studied my butt off for CCRN because so much of it is stuff I've never done or even seen. I answered questions on IABP too but I've never even SEEN one. We've never used paralytics in our ICU. Don't use fentanyl. Only recently was propofol approved for use. We still use a sling-scale for weighing patients (no scales in the beds). Maybe have had 3 - 4 swan-ganz catheters IN A YEAR.

I can answer the theoretical questions -- but the nuts-and-bolts of "how-to-mix" -- well, I've never done it. PUSHING epi in a code is a completely different animal than hanging an epi drip.

As I stated earlier, our ICU has been **LOW** intensity. Mostly respiratory failure kinda stuff. Very little cardiac stuff. I'm trying to learn here. Please don't make me feel like I can't ask questions. Things are changing fast in our ICU now that we have some hot-shot intensivists in place. I think it is great and I'm trying to come up to speed FAST.

I appreciate your input on the epi drip.

rstewart · Sep 18, 2003

I do understand how you might feel that my negative response was directed toward you personally; I do apologize for any misunderstanding.

On the other hand, I must tell you that epi drips are part of ACLS (not just push). You see them used for bradycardias that are just this side of PEA or asystole and they do appear on the symptomatic brady algorithm. (right after dopamine). My point was, there was a time when in order to complete a course in ACLS you had to know that drug (action, how to mix, dose etc.) In fact, you had to know all your emergency drugs.That such basic information is no longer required is certainly not your fault; you are obviously a very self motivated professional. But it drives me crazy that these days a code leader could call for an epi gtt and an ACLS nurse would not know where to begin.

Similarly, the CCRN certification used to mean that you had to DO a certain amount of things at the bedside----not just know about them. If you didn't perform enough of the skills at the bedside during the recertification period-----no recert. That too has changed.

And now we are at a point where answering less than 75 questions correctly can get you a pass on the NCLEX; as you may know, the exam used to take 2 full days. Those of us with concerns were told that The Computerized Adaptive Testing methodology permitted these quickie licensure exams. They were just as good. But those of us who have been doing this awhile could see otherwise. And although it will never be admitted to publicly, can there be any doubt that the soon to be introduced Alternative Test Items are an attempt to partially mitigate the obvious deficiencies with the current test?

Obviously your innocent question has struck a nerve; and again I do apologize to you. I just believe that nurses are being shortchanged these days and despite the licenses, certs etc. I have personally witnessed the result at the bedside.

gwenith, BSN, RN · Sep 18, 2003

Zee don't feel bad there are a lot more nurses in your situation than you would believe. This is a problem world wide. The classic measure for inservice education is a skill that is required often enough to need proficiency but actually performed often enough for staff to gain proficiency.

We call epinephrine adrenaline.

So for adrenaline and for nor-adrenaline we add 6 mgms in 100 mls(well 94 mls to be absolutely accurate) and titrate the doseage based on Mcg/minute. This makes it easy as the mls/minute = Mcg/minute. We don't weigh we estimate weight and titrate to effect.

Is this an easier way to look at it??

I gather this is fairly common way of using adrenaline over here. Our ACLS only goes into the needed routine during an arrest. I know that when they set up the transition program to ICU they nearly tore thier hair out as it had to encompass the entire state and there were so many levels of ICU from 4 bed units in small towns through to 36 bed units in the metropolitan hospitals. Because of the differening levels of knowledge there are so many many nurses in your postion Zee - they have the knowledge and not the experience and that is frightening for them.

Once you have looked after a couple of adrenaline infusions and are able to see first hand the effects you will feel less frightened.

zambezi, BSN, RN · Sep 19, 2003

We mix our epi gtts as 2mg/250 D5w (epi 1:1000, or 2mls). We also start at one-two mcg and titrate to desired effect, if necessary we can double stregnth the epi but obviously would call the doctor first to see if they wanted to continue with the wpi or try another drug.

Zee_RN, BSN, RN · Sep 20, 2003

OK, here's part of my confusion. I wanted to double check the records at work before I posted again and exposed myself.

The epi drip that we had running was mixed by pharmacy. The concentration was 8 mg of epi (1:1000) in 250cc D5W. The ordered infusion rate was 0.1 mcg/kg/min. Checked with another nurse who has worked at places other than my podunk ICU and she said they used to mix 16 mg in 250cc D5W.

So this is different than what the ACLS stuff says. Thoughts?

Thank you!

New CCU RN · Sep 20, 2003

I don't think that would be a big deal. Just make sure your math comes out to the correct amount to be administered.

We often change concentrations per what pharmacy says is ok in order to decrease fluid intake, etc. ie) our neo we concentrate anywhere from 4mg-64mg in 250mL all dependant on the dose required and the fluid status of the patient.

I wouldn't sweat 8mg vs 16mg.... it is kinda the thing that either is correct.

gwenith, BSN, RN · Sep 20, 2003

We deliberately keep a very simple formula with little variation to reduce errors. This is particularly important if you are titrating to effect as it allows you to better predict teh effect of titration.

New CCU RN · Sep 20, 2003

Well, what if a patient needs 200 mcg/min of Neo and their drip is concentrated at 8mg:250mL. You are going to be changing the bag constantly...driving pharmacy crazy, and dumping an unnecessary amount of fluid into the patient....

We program our pumps and then verify the math and must do this q2h to avoid errors.

gwenith, BSN, RN · Sep 27, 2003

We rarely if ever give 200 mcg/min of "neo" BTW what is neo??? Pharmacy does not make up our bags - we do.

If we were pushed we would use a bigger bag - same concentration.

XIGRIS · Sep 27, 2003

Hi there,

Here's my take on this topic:

Different institutions have different protocols on how an Epi is mixed. Be it 4mg or 8mg, it doesn't really matter. What is more important is that you know what to expect with an EPi drip and its effects hemodynamically.