I have query about epinephrine. As we know that epinephrine is available in 2 strengths
Epinephrine ampule i.e. 1mg /ml 1:1000
Epinephrine epipen i.e. 1 mg ( 0.1mg/ml ) 1:10,000 ( prefilled syringe)
We know that epinephrine epipen (prefilled syringe ) is used IV for cardiac arrest . AND epinephrine 1mg/ml is used IM /SC for anaphylactic shock
My question is if Epinephrine epipen i.e. 1 mg ( 0.1mg/ml ) 1:10,000 is not available ( out of stock ) . can we use epinephrine ampule 1mg/ml i.e 1:1000 IV without dilution ? BECAUSE in case of code blue ( cardiac arrest ) there is no time for dilution of epinephrine ampule 1mg/ml in 10ml saline and then administer to the patient
The epinephrine 1mg dose will be the same and the formulation in that ampule can also be given as IV. If you must give as a straight undiluted 1mg/1mL IV push then you should follow up with a saline flush of at least 20 mL to ensure the dose is delivered. I say 20 mL since I use a 10 mL flush after delivering a 1mg/10 mL epi premixed syringe.
My procedure would be to break the ampule, pull up the 1mg/1mL dose, change to filter needled (to filter out glass particles from ampule), then open a saline flush 10mL and squirt out just over 1 mL or pull back the plunger to accommodate more volume, then inject the epinephrine into the flush (through the luer lock hole), then give as IV push to patient. Follow with another flush afterwards.
when faced with this situation in the past, we made it a normal practice to quickly prepare couple of epinephrine 1 mg / 10 mL doses using the ampoule and saline 10 Ml at the start of any code blue and properly label it for use. As you give a dose to nurse/physician to administer, you prepare another one (cost was not prohibitive). This was possible because we had a pharmacist participating in all code blue events. It was a big relieve for our nurses to know that we had an expert available there side by side to help in this life threatening situation.
First of all I have to emphasize, as an important link in the health care team Pharmacy role is beyond doubt is expanding and as well as challenging, as team member recorded the active role of Pharmacy Services in the code situation and dispensing the easy to use Epinephrine in the event of drug shortages, is a salient example .It is big relief for the nurses and avoid any eventual dosage calculations queries from the nursing units, which is invariably the case.
ensuring that the correct concentration is administered in a similar scenario is vital.
With regards to the use of saline flush for the preparation of IV push doses, kindly refer to 3.6 in the attached “ISMP Safe Practice Guidelines for Adult IV Push Medications” stating that this practice must be eliminated.
You are absolutely correct in your statement but I believe the warnings from ISMP 3.6 refer to the routine dilution of drugs in the flush syringe for non-emergency use with the risk of mislabeling (or absent label) being there and inadvertently giving the wrong drug to the patient. In the original case, in the absence of premixed syringes and during a crisis situation with very limited time, the syringe is being mixed and immediately being administered to the patient within a matter of seconds (benefits greatly outweigh the risks scenario). The syringe would never have the mislabeling risk as it would be given immediately by the pharmacist anyway. I believe this practice in a code blue situation is not what the ISMP is intending to cover, but certainly for the routine compounding of medications in flushes for routine use, in a medical office, or for routine procedures as batched by the pharmacy.
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