# Racemic Epi



## Trashtruck (Apr 12, 2012)

Curious,
Is anybody else using racemic epi for croup?


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## 46Young (Apr 12, 2012)

We use nebulized epi. I don't see the major difference from that and racemic epi other than racemic epi is more expensive.


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## johnrsemt (Apr 12, 2012)

I have use 1:1,000 Epi nebulized for both  croup and for asthma that Albuterol didn't help.     Worked great.     
  I don't know if Racemic Epi would be any different


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## CCNRMedic1982 (Apr 12, 2012)

Other than it being more expensive it is an isomer to epinephrine. Or it just has a different chemical arrangement. It still works on alpha and beta cells but slightly beta 2 specific. I have used both and see no obvious difference. Had the same question and after some research that's basically what I came up with. But really depends on what your service can afford and what your med director likes .


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## MSDeltaFlt (Apr 12, 2012)

The last literature I saw about Racemic Epi is that it's 1:100 epi making very potent.  When needed for croup it can be beneficial. However, that strong of a concentration can cause a rebound bronchospasm. Which is why several ER's will use it only when nothing else works.


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## Cawolf86 (Apr 15, 2012)

Los Angeles County protocol offers the use of 2.5 - 5mg of Epi 1:1,000 via nebulizer for croup - not Racemic though.


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## Handsome Robb (Apr 15, 2012)

We use it. I never personally have used it or seen it used. 

Less than 6 months old get 0.25 mL of racemic epi for croup. Greater than 6 months gets 0.5 mL.


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## NomadicMedic (Apr 16, 2012)

No racemic epi in Delaware. Too expensive and no difference in outcome when compared to regular epi. Our croup protocols include 5ml of 1:1000 via neb.


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## TYMEDIC (Apr 21, 2012)

Do u guys prepare it different. Such as diluting it down with fluid. ? Or just straight episode?  Interesting


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## kindofafireguy (Apr 22, 2012)

We have it, and it's in our protocols, though I've yet to use it or meet anyone who has.


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## Farmer2DO (Apr 22, 2012)

We use regular epi 1:1000.  For ages:

<1:  0.5 ml/kg, max 2.5 mg
1-4:  2.5 ml
>4:  5 ml

All diluted with 3 ml NS.  I use it probably half a dozen times a year.  (In the northeast, the cool wet weather of fall and spring are notorious for croup.)  

My only concern is that we have to use IV NS.  We don't carry respiratory grade saline.


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## NomadicMedic (Apr 22, 2012)

Farmer2DO said:


> My only concern is that we have to use IV NS.  We don't carry respiratory grade saline.



Am I missing something? Isn't sterile saline sterile saline?


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## NYMedic828 (Apr 22, 2012)

Half a dozen times a year? Damn. I don't know more than a couple of people out here who have even had a croup patient.

Last I knew there is no such thing as respiratory grade saline? Normal saline is normal saline... It's always sterile.


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## TYMEDIC (Apr 22, 2012)

Farmer2DO said:


> We use regular epi 1:1000.  For ages:
> 
> <1:  0.5 ml/kg, max 2.5 mg
> 1-4:  2.5 ml
> ...




Is the dosing the total end sum with the dilution included (3ml NS). We have the epi multi dosing vial here. Ive had several cases of croup here and needed additional medication refractory to dual nebs for improvements in peds.


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## JakeEMTP (Apr 22, 2012)

NYMedic828 said:


> Last I knew there is no such thing as respiratory grade saline? Normal saline is normal saline... It's always sterile.



Respiratory grade doesn't mean sterile.  Respiratory grade means no preservatives. A lot of NS has benzyl alcohol as the preservative which is not good for inhalation. If you run calls where you might have onocology patients or central lines, you need to check out what is in your saline as a preservative.


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## NomadicMedic (Apr 22, 2012)

Really? Boy, I wish Vent Medic was still around.


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## Farmer2DO (Apr 23, 2012)

n7lxi said:


> Am I missing something? Isn't sterile saline sterile saline?



As I understand it, all the saline (respiratory and IV) is sterile.  But the respiratory grade is also filtered to a finer level.  Just because all the things floating around in IV saline are dead (sterile) doesn't mean you want to inhale that stuff into your lungs.

Again, as I understand it.


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## Handsome Robb (Apr 23, 2012)

I'm assuming the pinkish NS bullets packaged with our Racemic Epi are respiratory grade, I'll check on Tuesday.

n7 I'm in the same boat, I had no idea about respiratory grade NS.


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## NomadicMedic (Apr 23, 2012)

NVRob said:


> I'm assuming the pinkish NS bullets packaged with our Racemic Epi are respiratory grade, I'll check on Tuesday.
> 
> n7 I'm in the same boat, I had no idea about respiratory grade NS.



I can't find anything about "respiratory grade" 0.9% Normal saline anywhere... and my Google-Fu is not weak. 

I do know that the "saline solution" sold OTC for contact lens rewetting and care has preservatives in it. I certainly wouldn't advise dripping that stuff into a neb.  However, I don't think you’d have any issues with drawing 2.5ml of NS out of a fresh IV bag, if you didn't have a pink saline bullet.


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## Aidey (Apr 23, 2012)

Search including the term bacteriostatic (I think I spelled it right). Bacteriostatic saline, which usually comes in multi dose vials, contains a preservative to prevent bacteria growth. That stuff shouldn't be used for inhalation, and can cause more respiratory issues if it is. I looked at the saline in our IV bags and saline flushes and there were no preservatives listed in those.


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## JakeEMTP (Apr 23, 2012)

Try using the word bacteriostatic saline in your search which is what your IV solutions, flushes or vials might say.  The little plastic bottles are usually bacteriostatic.

The preservatives do make a difference in how long you can store something or keep it open and who to use it on epecially when it comes to children. I guess I should have given you more information earlier. I thought you were just joking around.

This is why you don't use saline with preservatives.
http://findarticles.com/p/articles/mi_m0689/is_n1_v40/ai_16392591/

I think these are the little pink plasitc snap vials.
http://www.drugs.com/pro/sodium-chloride-inhalation-solution.html.

The box they come in will say something like  

_Sterile, non-pyrogenic, preservative-free single-use vials for respiratory therapy.
No bacteriostatic agent or other preservative added.

INDICATIONS: Contents of these vials are for use in respiratory therapy and for tracheal lavage._


You definitely wouldn't want to lavage the bacteriostatic stuff into a trach or down an ETT.


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