# Epi Drips



## Jon (Sep 15, 2009)

Ok...my program briefly touched base on Epi Drips.

I was talking with a student today about epi drips.

Can someone please explain the where and why of epi drips? how would I create one?

Thanks,

Jon


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## thowle (Sep 15, 2009)

http://allnurses.com/micu-sicu-nursing/epinephrine-drips-44756.html


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## fma08 (Sep 15, 2009)

I know there are many other uses for it, but the first one that comes to my mind is a last ditch effort for if the pacer fails to capture.


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## AZFF/EMT (Sep 15, 2009)

Our severe alergic reaction protocol has an epi drip 2-10mcg/min for unresolved anaphylaxis post sq epi. States start with epi sq 0.01mg/kg up to 0.5mg, then benadryl 50mg, Albuterol SVN/BVM, Solu-medrol 125mg.

If unresolved with sq epi start an epi infusion.


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## ResTech (Sep 15, 2009)

To make an Epi drip... 1mg of epi in 250mL NSS = 4mcg/ml


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## medic_texas (Sep 15, 2009)

Epi gtts are generally used for hypotensive patients (septic shock anyone?) who do not respond to vasopressors (such as levophed and dopamine).  I can see it's use for anaphylactic shock as well in pre-hospital situations however I would be hesitant without a pump and a very educated/competent staff.    

1mg in 250ml usually (NS or D5W) of 1:1,000 Epi (that's very important!).  Off the top of my head, I think the dose range is 2-10mcg/min is the range you can work in, starting low and working up of course.


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## medic_texas (Sep 15, 2009)

fma08 said:


> I know there are many other uses for it, but the first one that comes to my mind is a last ditch effort for if the pacer fails to capture.



You sure about that one?


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## AZFF/EMT (Sep 15, 2009)

Also for symtomatic brady...Atropine, Pacing, epi, dope.


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## SurgeWSE (Sep 16, 2009)

We use it in symptomatic brady after other stuff.  We use it earlier in kids with bradycardia.  It also has a place in refractory anaphylaxis or bronchospasm.


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## MSDeltaFlt (Sep 16, 2009)

Jon said:


> Ok...my program briefly touched base on Epi Drips.
> 
> I was talking with a student today about epi drips.
> 
> ...


 
The where and the why? Simple. When you've maxed out your other vasopressors and your pt's BP is still in the crapper, you will add and epi drip. Not change, *add*.

1mg of 1:1,000 epinephrine in a 250mL of NS or D5 is great if you have a pump. If you don't then you've got to figure out a way to administer the drug with as little chance of crewing the pooch as possible. The best way to do that is to make the epi drip a 1:1 concentration.

A 1:1 concentration is a 1mcg:1mL concentration. 1mg in 250mL is 4mcg/mL. However, 1mg in 1000mL is 1mcg/mL. Get a liter bag, 10gtt set, a 10cc syringe, and an amp of epi. Pull out 10cc from the liter bag, push in the whole amp of epi, shake well, and you have your 1:1. Don't forget to label the bag. Remember, in a 60 gtt set, drops per minute equals to cc's per hour.

*mcg 2mcg 3mcg 4mcg...*
*gtts 2gtts 3gtts 4gtts...*

I could go all the way to 20mcgs/min, but you get my point.

I'm sure others may have better ideas, but this is how I would do it.


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## medic_texas (Sep 16, 2009)

MSDeltaFlt said:


> The where and the why? Simple. When you've maxed out your other vasopressors and your pt's BP is still in the crapper, you will add and epi drip. Not change, *add*.
> 
> 1mg of 1:1,000 epinephrine in a 250mL of NS or D5 is great if you have a pump. If you don't then you've got to figure out a way to administer the drug with as little chance of crewing the pooch as possible. The best way to do that is to make the epi drip a 1:1 concentration.
> 
> ...




That's awesome.  I didn't even think about doing that.  

Learn something new every day.  I can go back to bed now


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## fma08 (Sep 16, 2009)

medic_texas said:


> You sure about that one?



Not a very good argument coming up on my end, but, that's one situation my ACLS instructor taught me. It is also mentioned in the Bradycardia algorithm (http://www.acls.net/acls2005/brady.htm). I know people have mixed feelings on ACLS, but since the protocols I operate under are based off of ACLS... I'm stuck with it, until something changes anyway.


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## ResTech (Sep 16, 2009)

> 1mg of 1:1,000 epinephrine in a 250mL of NS or D5 is great if you have a pump.



I am curious why you are saying this is not a good concentration in the absence of a pump. 

Most protocols call for 2-4mcg/min to start and titrate up. So using a 60gtts/set with the 4mcg/mL concentration... its an initial 60gtts for 4mcg/min or 30gtts for 2mcg/min. I don't see how that is hard to mess up without a pump. Although, I do like your 1:1 solution for the epi drip since its less drops to count. 

Now just a question about using a macro drip set with an infusion.... wouldn't there be more of a chance to OD the patient or administer a less than desireable dose in the circumstance that the flow rate gets inadvertently altered in the field since it would take a lot less flow to administer more medication versus the micro drip set? I was always taught to only use a micro drip set when starting a infusion. 

I have yet to see a 911 ALS service carry pumps around here.


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## MrBrown (Sep 16, 2009)

We only hang two drips - adrenaline and amiodarone.

They are only used for sympto brady, severe asthma and anaphylaxis 

We take 1mg, dilute in 1 litre of saline and run PRN


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## stonez (Sep 17, 2009)

We use for post cardiac arrest hypotension that is not improving (<70 SBP).
We also use it for resistant symptomatic bradycardia.
Dose 2-10mcg per min (Adult dose).
So we use 2 amps (2mg) into 200mls which equals 10mcg per ml.


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## TransportJockey (Sep 17, 2009)

MSDeltaFlt said:


> The where and the why? Simple. When you've maxed out your other vasopressors and your pt's BP is still in the crapper, you will add and epi drip. Not change, *add*.
> 
> 1mg of 1:1,000 epinephrine in a 250mL of NS or D5 is great if you have a pump. If you don't then you've got to figure out a way to administer the drug with as little chance of crewing the pooch as possible. The best way to do that is to make the epi drip a 1:1 concentration.
> 
> ...



Ya know, you just summed up in one post a very confusing day for us in lab during class. My instructors believed that the best way for us to learn epi drips was to break us into groups and have us come up with a field expedient way to run epi drips. 

We learned it, but knowing the above beforehand would have been nice


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## Akulahawk (Sep 17, 2009)

jtpaintball70 said:


> Ya know, you just summed up in one post a very confusing day for us in lab during class. My instructors believed that the best way for us to learn epi drips was to break us into groups and have us come up with a field expedient way to run epi drips.
> 
> We learned it, but knowing the above beforehand would have been nice


The exercise provided you with how to figure out how to make IV med drips using meds that are already on the truck that aren't prepackaged as a drip... You take an already existing prepackaged bag... and already prepackaged med... and figure out how to make it work so that the desired dosages can be administered. 

The fact that it was figuring out how to do it with epi was just the means to get you all thinking...


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## mrhunt (Nov 4, 2019)

Sooooooooo someone will probally yell at me for reviving an old thread but trying to not start a new one......

If im giving A dirty EPI drip at 2mcg/min Which is our protocols, in a 60 drop set...(or 10 drop set......whatever)
Id just do a 1:1 Epi in a liter of NS which would give me a 1 to 1 concentration and every ml would equal 1 MCG.....

Weight isnt a factor and im not caring about an hourly rate here as transport times are Short.....LONGEST would be one hour.....Anyways. 

How am i breaking that down Barney style to drops per second? sorry its like 11pm and im trying to brush up on this stuff and my mind is shot.

10gtts is 10drops equaling 1ML in 60 seconds.... wanna give 2ML a minute which equals 2MCG a min.....Soooooooo..... 20 DROPS in a minute....
That equals roughly 6 drops every 20 seconds Because 20 X 6 = 60 seconds?.......
or roughly 3 drops every 10 Seconds....... 1 Drop Every 3 Seconds

Or Just doing a 60 Drop set which is more easily controlled gives you 2 drops every Second for a 2MCG concentration.....Correct?......


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## Peak (Nov 4, 2019)

I highly recommend dimensional anyalsis any time you are trying to do unit conversions. That being said if your concentration is 1mg/1liter (or 1 mcg/mL) you get 0.33 repeating gtt/sec on a 10 gtt drip set or 2 gtt/sec on a 60gtt set. 

I do think this is one of the many reasons that EMS should have pumps on the ambulance, even with correct math it is very difficult initiate and maintain the correct drip rate. 

Additionally it isn't uncommon that we are giving 20 mcg/min of epi on our adults that would work out to 3.33 repeating gtt/sec on a 10 gtt set or 20 gtt/sec /min on a 60 gtt set, both of which are very difficult to measure let alone feasibly give in most peripheral access. In my opinion I'd far rather give standard concentration of 4mcg/mL on a pump (or 60gtt set if that is not possible) than to give the dirty drip concentration on a 10 gtt set. 

I'd also highly recommend having a dedicated line with a chaser fluid at a consistent rate to help push you pressor in the line, especially at lower rates. In the situations that we would worry about fluid overload the time to the hospital is likely insignificant but at slower rate you really need something to push the fluid through the IV.


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## mrhunt (Nov 4, 2019)

hence the piggy back. i always sorta wondered why it was there. i always thought the med / fluid itself did a fine job of "pushing itself in"....whats the exact logic behind that? were just ensuring theres absolutely no backflow due to the low infusion rate of the med?


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## Peak (Nov 4, 2019)

Perhaps the term piggy back might mean different things to different people. To me piggyback drips are running as a secondary while your primary fluid using the differential gravitational force to drive the secondary fluid in lieu of the primary fluid. I guess you could mess the with the secondary clamp but I would personally rather just string up a second line with your chaser. If you change the gravity on your bags at all it can change the differential rate which gravity pushes in your primary and secondary on your piggyback. 

In the world of critical care we almost never use piggyback as a way of delivering any medicaitons (with the exception of as a flush for chemo, antibiotics, etc...). Rather medications that are necessitate a strict rate are given on a independent primary drip set.  

Without a chaser any changes to drip rate are going to be delayed by whatever the priming volume is on the set. If you are in theory only running one drug through a site that isn't a problem, but if you are running more than one drug you start to end up with some weirdness between wherever your meds Y-site and the actual infusion site, in some cases this can be several mLs. Even a priming volume of 0.5 mL with a drip rate of 0.33 mL/hr ends up being over an hour before the change may reach the patient. The chaser fluid helps to mitigate this by over all increasing the infusion rate without increasing the amount of drug given so that any changes are quicker in effect.


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## Jn1232th (Nov 4, 2019)

Symptomatic Brady, hypotensive refractory to fluid, rosc ( but different dosage). 

Was taught 1mg of 1mg/10ml epi. In 250ml bag. Equal 4mcg/ml.  
Brady/hypotension infuse 2-10 mcg/min 

Rosc will be 0.1 to 0.5 mcg/kg/min. 

But area recently hired in doesn’t use epi drips and instead has push dose epi.


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## E tank (Nov 4, 2019)

justin1232 said:


> Symptomatic Brady, hypotensive refractory to fluid, rosc ( but different dosage).
> 
> Was taught 1mg of 1mg/10ml epi. In 250ml bag. Equal 4mcg/ml.
> Brady/hypotension infuse 2-10 mcg/min
> ...



You mean .01-.05 mcg/kg/min?


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## Jn1232th (Nov 4, 2019)

E tank said:


> You mean .01-.05 mcg/kg/min?



Oh yeah haha forgot those zero’s there


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## Jn1232th (Nov 4, 2019)

E tank said:


> You mean .01-.05 mcg/kg/min?



Wait no haha it is 0.1 to 0.5 mcg/kg/min basing off ACLS guidelines that is.


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## E tank (Nov 4, 2019)

justin1232 said:


> Wait no haha it is 0.1 to 0.5 mcg/kg/min basing off ACLS guidelines that is.



You're right. Sorry. That is a lot of epi. I don't go by ACLS guidelines. I would say that a generic start to post ROSC hypotention of 0.1 is a little heavy handed...but they didn't ask me, so there's that. 

In my patient population (cardiothoracic/vascular) if I have someone on 0.1 mcg/kg/min of epi, the patient us unusually unstable. But that is also in the contexts of the other drips I have available to me that will mitigate the need for so much. 

A quick and dirty way to get a drip started quickly to buy yourself time to get your bearings and settle into a plan is to add one vial of any inopressor you're interested in to 250 cc of fluid (in this case epi, which should be 1 mg) and start it at 30 drops a minute. 

So that will give you 4 mcg/min or .05 mcg/kg/min in an 80 kg patient. It's enough to get you started. 

If you do that for norepi, you get 0.1/kg/min or 8 mcgs/min...
vasopressin...2.4 units/hour...
dopamine (1 vial of 400mg)....10/kg/min

If some doses are a little heavy handed or not aggressive enough,  titrate  up or down once you get your bearings. The point is to get it rolling and working without a lot of analysis and go from there.


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