Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

More Drug Shortage Paranoia – Epinephrine

As if an anesthesiologist has nothing else available, when there is a drug shortage. It has been a few years since ether was the only anesthetic.

The critical shortages led to a patient waking up during an operation and four patients dying, according to a new national survey of 1,800 health professionals conducted by the nonprofit Institute for Safe Medication Practices.[1]

A more accurate statement would be that these drug shortages have pointed out just how poorly people understand how to perform drug calculations.

This is especially complicated.

If we don’t have this –

First we panic, because even though there is no evidence of improved outcomes, this is something we have been trained to believe in more than good compressions. That is changing – at least a little bit.

Then we take a 1 mg/ml epinephrine ampule –

Then we take a 10 ml syringe. Here is an empty one, but we want a full one –

Pick one that is 10 ml – it is on the far right –

Squirt out 1 ml, which leaves 9 ml –

Break the ampule and draw the medication from the ampule into the syringe that has 1 ml of free space, since you squirted out 1 ml of saline –

That’s it. Take 1 ml of epinephrine, and draw it into a 10 ml saline syringe (after removing 1 ml saline) and you have miraculously converted 1:1,000 epinephrine to 1:10,000 epinephrine. OK. All you did was create a solution that is 10% of the original strength. Hardly a miracle, unless you are the one getting the medication error reports. Then it may seem as if just pushing the right preloaded syringe is a miracle.

“It is a mainstay in cardiac arrest,” said Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists. “In cardiac arrest, you want to be able to intervene very rapidly.”

The drug is a key item on crash carts in Mercy and other hospitals. When a patient goes “code blue,” hospital staffers rush the drug-filled crash cart to the bedside to try to restart the patient’s heart.

In some emergency incidents, hospital workers have had to stop, dilute the epinephrine and set up the syringe before administering it.

One code-blue patient in an undisclosed city died because the preloaded emergency syringe epinephrine wasn’t available.[1]

For realz?

The dead person became deader because the magic syringe wasn’t there?

This is just stupidity.

Maybe epinephrine helps resuscitate people and maybe it doesn’t. We don’t know. It doesn’t help to have these clowns making these irresponsible statements.

We have a shortage of epinephrine 1:10,000 prefilled syringes. What an excellent opportunity to compare the effects of real epinephrine with placebo epinephrine and double the supply of 1:10,000 epinephrine. It will double the supply in the areas where this study is set up.

Why don’t we find out if we should continue to use it?

So far, there is no research to show that epinephrine does improve survival.

One code-blue patient in an undisclosed city died because the preloaded emergency syringe epinephrine wasn’t available?

If we find out that epinephrine really does not improve survival, then what killed that code-blue patient?

Magic?

What if the AHA (American Heart Association) does not continue to recommend epinephrine for all cardiac arrests?

I realize that such an untraditional move is not very likely, even though it would be completely appropriate for a treatment not supported byevidence.

But what if the AHA pulls epinephrine from the guidelines completely?

Resuscitation drugs have not been shown to increase rate of survival to hospital discharge, and none has the impact of early and effective CPR and prompt defibrillation.[2]

Right now, the AHA is not making a strong recommendation for epinephrine. Maybe they will lower epinephrine from Class IIb (some experts are biased in favor of it) to Class Indeterminate (who knows?). The only other category below where epinephrine is now is Class III (possibly harmful) –

There is no clear evidence that epinephrine is helpful.

There is no clear evidence that epinephrine is harmful.

Is there a better definition of Indeterminate?

“It is alarming,” said Jason Likens, director of clinical services for the Emergency Medical Services Authority.[1]

Only if I am prone to panic.

Survey respondents attributed another death to the absence of an antibiotic and two deaths to administering the dosage for morphine when a substitute drug requiring a different dosage had to be administered.[1]

Perhaps an in-service on reading the label and dilution of medication would be a good idea. If that fails, the exciting world of fast food awaits. This is only more evidence that EMS education is broken.

There is also a video from the FDA (Food and Drug Administration) on this in a variety of formats –

Shortage of EPINEPHrine Syringes Can Cause Errors

I have also covered these drug shortages here, here, here, here, here, here, here, and here.

Footnotes:

[1] Oklahoma EMS Face Drug Shortage
by Sonya Colberg
The Oklahoman
Monday, October 4, 2010
Article at JEMS.com

[2] Part 7.2: Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Summary
Free Full Text from the AHA

.

Comments

  1. I found this particularly troubling:

    Survey respondents attributed another death to the absence of an antibiotic and two deaths to administering the dosage for morphine when a substitute drug requiring a different dosage had to be administered.

    What exactly was the substitute drug that wasn’t a suitable replacement for morphine and killed some folks? Did they even read the survey before responding?

Trackbacks

  1. […] This post was mentioned on Twitter by EMS Blogs, Chronicles of EMS. Chronicles of EMS said: More Drug Shortage Paranoia – Epinephrine http://bit.ly/bRutn8 Via @EMSblogs #CoEMS […]

  2. […] for PEA/Asystole.  In a huge step towards true evidence-based medicine (which is likely to make Rogue Medic’s day), the AHA removed atropine after a review of the evidence showed there is likely no benefit to […]

  3. […] I have recently written about why these drugs are inappropriate here, here, here, and here. […]

Speak Your Mind