mixing meds?

Nitecap · Mar 22, 2006

Sad to say when you push one drug after another, they all get mixed anyway.

Yeah they get mixed in the blood with every other molecule, toxin ect along for the ride. The issue here is not mixing the drug b/c many are compatible and wont precipitate or anything. The issue here is dosing, accountability for the narcs, carelessness, someone else coming up and pushing your stick of "white lightening" and not realizing it exactly what it was, infection and contamination and cost. Is it that beneficial to the pt to break the other vial just to mix a touch of this or that in when really the primary drug could be just as effective or safe. And like I said its could turn in to a litiginous issue if just once your mixing cause a screw up whether you did it or not you mixed it. I promise you they will have expert witnesses lined up to roast the mixing and really what aurguement do you have. Oh I had to pee so bad and forgot to tell my relief that I had half ketamine in a syringe he thought was all propofol and he emptied it in old man joe and I only planned to give half and he had an intraop MI and is now septic and the lawyers are going after the mixing as the cause of both events. When this could have been avoided by just drawing each up labeling each and giving seperatly.

MmacFN · Mar 22, 2006

excellent thread

I guess where I worry is incompatibility issues. While I know things are probably very different in the OR, the reality of compatibility issues has little to do with how it all ends up in the blood stream and more about how they react chemically in the same line or syringe. Are there no issues with these drugs?

The issue of a syringe which looks like diprivan but has other agents is also important.

rn29306 · Mar 22, 2006

Each to his own.

Pete495 · Mar 22, 2006

I mix Lidocaine and diprivan, and that is it. But that is becuz every single stinkin time the lido isn't in there, the pt. c/o burning, and it is always the last thing they remember. amazing they can't remember anything else before or after though.

As far as mixing other drugs, like diprivan and ketamine, that's just an accident waiting to happen, so I definitely agree nitecap. In any case, the syringe should be labeled, and compatibility should be followed.

What about mixing narcs with ABX? what do you guys do as far as shooting fentanyl in while the gentamycin or kefzol is infusing? I try to flush if I can, but many do not do this. Lets face it, you can't look up the compatibility of everything before you inject, so I just flush to be safe.

rn29306 · Mar 22, 2006

Are you going to avoid isoflurane on every heart due to the theoretical potential for coronary steal?

Are you going to avoid sevo like M&M recommends on any patient with renal disease?

No. Like I said, each to his own. If you don't feel comfortable letting someone else (for whatever reason) taking over your anesthetic or you can't label a syringe properly like the professional that you should be, then stay in the room and finish the case.

Happens all the time.

athomas91 · Mar 22, 2006

mixing diprivan with other agents is done frequently - the only concern i feel is viable is if contamination rates are higher... however, if diprivan is drawn up just prior to use - as it should be - then contamination shouldn't be any more of an issue if there is another drug mixed with it...

as far as confusion about what is in a syringe and not labeling correctly - that has nothing to do with whether it is safe to mix - that has to do with irresponsibilty in labeling your drugs - i know we all forget at times (it happens) however - one should NEVER assume what is in a syringe. it is most responsible to draw everything up separately and give separately - but if you argue this- than it should stand for ALL your medications ie. no mixing of glyco/neostig....

it is also (in my opinion) not a good idea to come to an opinion by what you read in a book without using the medications first hand and seeing what actually happens...

i have used propofol and etomidate - they weren't mixed in the same syringe - but i would give 2 cc propofol - 2 cc amidate - 2cc propofol --- you get the point.

it was a very effective way to manage a GI lab patient who could not tolerate hypotension...

How does etomidate hang around exactly? I know it works fast, less than a minute and its effects can wear off as soon as 3-5 min (depending on the text you read). I assume you meant the 75 min half life? In anycase, it appears it could be considered contraversial to be using diprivan and etomidate togeather as research seems to suggest each can potentiate the others hypotensive effects.
One concern I see is how etomidate can block the adrenal gland's production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure. This could lead to abnormal salt and water balance, lowered blood pressure, and, ultimately, shock. The fact that this can last up to 8 hours is a serious consideration and studies seems to suggest that they remain unresponsive to adrenocorticotropic hormone (ACTH) tx for that time. Depending on co-morbities, this is a serious issue.
When i think about diprivan and long term sedation im concerned about oppertunistic bacteria loving that emulsion base. Secondly, the tissue uptake of the drug can be severe after a 5-0 day period slowing recovery for sure. As for use intitially, im not sure that etomidate would not be used but i dont think you would be wise to mix them in one syringe at all. Secondly the doses would have to be carefully adjusted to account for the synergy between the two.

my first question is what research exactly are you referring to when you state they potentiate one anothers hypotensive effects??

secondly, one full intubating dose of etomidate MAY (only a chance) suppress the adrenal cortex for up to 8 hours - that is why it isn't used in prolonged infusions - however - would you chance that - or just use propofol - drop the pressure and chance the CV damage or stroke in that unstable patient. when we are speaking anesthesia-wise of mixing meds - we are talking about a push for induction or a 15 min infusion mixture for a MAC case. either way - it isn't the full intubating dose - so your risk for adrenal suppression is even lower.

finally,

we account for all our medications and their synergy - that is why they are used - on induction one may use propofol, versed, fentanyl, lidocaine... all of which potientiate one another - so accounting for synergy is what one is doing by mixing the two agents.

just my 2 cents..

i agree w/ the OP - i think some studies regarding these issues would be beneficial - until then - ...

just my 2 cents.

rn29306 · Mar 22, 2006

Is it that beneficial to the pt to break the other vial just to mix a touch of this or that in when really the primary drug could be just as effective or safe.

Surely you understand the issue of synergism. Less total propofol and less total ketamine. Reap the benefits of both.

A little story to bust your above quote. At our facility we do GI cases in the peds hospital usually with just propofol and MAC it. Weight-based PO versed in POH. No IV versed or fentayl for most young kids. Patients approaching the teenage years, esp males, can take upwards of 800 mg of propofol just to stay on the table during a MAC case. Guess what happens in PACU when MD is no longer running 9 feet of snake up the rear? They sleep in PACU for about an hour. So for these guys they get usually 1, maybe 2mls if full-sized male of versed and maybe 1 of fentanyl prior to procedure and titration of propofol during the case. Kids pop up outta PACU and no problems in minimal time.

Synergism is everywhere in anesthesia. You can actually do a case strictly with morphine, like in the olde days. But you had to use so much pts looked like a beet for about 15 minutes from histamine release, had extreme hypotension, and were hung over for a significant amount of time post-op. All anesthetics are synergistic and that is why you make the big bucks. If it were easy, punks off the streets would be doing this.

And like I said its could turn in to a litiginous issue if just once your mixing cause a screw up whether you did it or not you mixed it. I promise you they will have expert witnesses lined up to roast the mixing and really what aurguement do you have. Oh I had to pee so bad and forgot to tell my relief that I had half ketamine in a syringe he thought was all propofol and he emptied it in old man joe and I only planned to give half and he had an intraop MI and is now septic and the lawyers are going after the mixing as the cause of both events.

That's why we are professionals and you are expected not to do dumb, idiotic crap like this.

MmacFN · Mar 22, 2006

Hey thomas

Ive used all of those drugs on many occasions. Im very farmiliar with them and none fo what i wrote was out of a book. In anycase, there are certainly studies which suggest diprivan has hypotensive effects as well as etomidate (though rare). It stands to reason that adding drugs to the mix potentiate the risk for hypotension. Similar to how adding multiple antiarrythmics potentiate the risks of each individually (proarrythmic effect).

While i agree that etomidate has a low risk of adrenal suppression and that its usually only associated with intubation doses these are the doses i give on a regular basis so its of some interest to me :)

Great info and i love getting a glimpse into the CRNA world!

mixing diprivan with other agents is done frequently - the only concern i feel is viable is if contamination rates are higher... however, if diprivan is drawn up just prior to use - as it should be - then contamination shouldn't be any more of an issue if there is another drug mixed with it...
as far as confusion about what is in a syringe and not labeling correctly - that has nothing to do with whether it is safe to mix - that has to do with irresponsibilty in labeling your drugs - i know we all forget at times (it happens) however - one should NEVER assume what is in a syringe. it is most responsible to draw everything up separately and give separately - but if you argue this- than it should stand for ALL your medications ie. no mixing of glyco/neostig....
it is also (in my opinion) not a good idea to come to an opinion by what you read in a book without using the medications first hand and seeing what actually happens...
i have used propofol and etomidate - they weren't mixed in the same syringe - but i would give 2 cc propofol - 2 cc amidate - 2cc propofol --- you get the point.
it was a very effective way to manage a GI lab patient who could not tolerate hypotension...
my first question is what research exactly are you referring to when you state they potentiate one anothers hypotensive effects??
secondly, one full intubating dose of etomidate MAY (only a chance) suppress the adrenal cortex for up to 8 hours - that is why it isn't used in prolonged infusions - however - would you chance that - or just use propofol - drop the pressure and chance the CV damage or stroke in that unstable patient. when we are speaking anesthesia-wise of mixing meds - we are talking about a push for induction or a 15 min infusion mixture for a MAC case. either way - it isn't the full intubating dose - so your risk for adrenal suppression is even lower.
finally,
we account for all our medications and their synergy - that is why they are used - on induction one may use propofol, versed, fentanyl, lidocaine... all of which potientiate one another - so accounting for synergy is what one is doing by mixing the two agents.
just my 2 cents..
i agree w/ the OP - i think some studies regarding these issues would be beneficial - until then - ...
just my 2 cents.

EmeraldNYL, BSN, RN · Mar 29, 2006

According to my didactic instructors, you shouldn't mix Lido and Propofol because of the potential to form micro lipid emboli. Technically you can just give a little IV lido before the Prop to stop burning, but everyone mixes it to save time.

And if you go to court, how are they necessarily gonna know that you mixed the meds? Sometimes in the anesthesia record I put meds on the same line, like Decadron/Zofran, but that doesn't necessarily mean I mixed the two, I just put them together to save space because there is never enough room to write!!

Wow, such a hotbed of controversy......