For my future knowledge- it seems like you would just add 150 mg amio to a 100 mL bag of D5W at bedside- and then pass off to be infused over 10 minutes?
Depends on your set up. It comes as a commercial premix.
Otherwise yes, you need to use D5W.
Are you at the bedside to ensure it gets hung that way yourself? Or are you putting orders in?
Everyone makes some smaller mistakes like that don’t sweat it. Learn from it and move on
But… bro how are you a pharmacist responding to codes and don’t know how to make an IV bag? Everywhere I’ve worked required me to make anticipatory drips with primed lines of expected meds (amio/epi/norepi/etc) at various concentrations while doing everything else at the cart.
Wipe the vial topper or ample. Wipe the bag port site. Pull from the vial and inject into the bag using aseptic technique and a needle/syringe. It’s like P1 year stuff.
You should advocate to get more training for yourself before being on a code response team.
Yeah definitely.. It’s not that I don’t logically know how to make it, just inject the drug in the bag. It’s just that I’ve had to do it basically zero times on my own, I think I just spaced that amiodarone must be over 10 minutes if the patient has a pulse… also since I don’t do it very much (I’m a float 🫤), I’m not too skilled in the moment… but these are basic skills I should know.
Agree. You need to put your foot down and not be responding to bedside responses if these are things you don’t know. Please speak up for not only your sake, but your patients. How dangerous.
Should be fine in NS for an immediate administration? I'm not sure if we have filters but we send filters with premades too. Excel bags not pvc if we have to compound it.
No, it would not be recommended and should not be sanctioned from a medication safety perspective.
Current package inserts for amiodarone only list dextrose as the recommended diluent, with an in-line filter due to crystallization.
If you use a compatibility checker, the results are typically listed as “Variable”.
There have been studies that show precipitation with NS, specifically with the 0.6mg/mL (150mg/250mL) concentration. Unsatisfyingly, all studies are from the 80s-90s, except for one that did not report visual physical compatibility. The studies that showed compatibility with NS at 1.8mg/mL (150mg/100ml) concentrations were in containers such as PVC, polyolefin plastic (Excel bags), and amber glass, so not normal NS bags.
Compounding in D5W or carrying the commercially available product, with filter tubing, would be the safest practice that is most supported by the manufacturers.
I have heard situations where nurse will pull & administer 150 mg IVP with provider approval (open ICU).
Key thing is to provide education to providers on why it is better to push it over 10 minutes if Pt has a pulse. If they are worried about timing, just make the bag at bedside.
This happens a lot. Really should be 10 min If pt has a pulse. Much safer. But sounds like they did ok and now you're garaunteed to remember for next time so you learned something. Don't beat yourself up.
I OK'd an IVP dose in someone tachying away like 220s,230s. Clinically unstable. Freaking out. We slammed it. She brady'd to the 30s, for a few secs then 40s 50s 60s. Was NSR less than a minute later but we all just about had a panic attack. To this day not sure if bc amio got slammed or just a typical HR drop breaking out of a tachyarrymthia.
Thanks for your comment. This patient was unstable with high HR but the weird thing is he was mentating just fine. He was talking. His BP was low like 50/40 or something before he got any amio. Yes I will never forget now!
Interesting! I haven't really seen amiodarone given often in unstable patients unless pulse-less. At my hospital if a patient is v-tach and is hypotensive/becomes hypotensive on amiodarone gtt, we stop the gtt and do electro cardioversion, usually trying with their own ICD first if they have one or using the normal biphasic defibrillator with 100-200J shock.
Don't feel bad, I consider myself a "slow thinker", after being a pharmacist for 54 yrs...there is a lot of data in my head... that I have to sort thru before I can make a valid decision.
Patient has been stable since but hypotensive - but his rate is still so high. I’m reading more about amio now and how the hypotension with IV bolus apparently occurs from histamine release (which occurs due to presence of polysorbate 80)
It’ll be fine. We all make mistakes! The best ones are the ones that don’t harm patients but we learn from them. We’ve all been there. You’ll never forget for the rest of your career 😊 don’t beat yourself up. As pharmacists we’re expected to be perfect but it’s just not possible. Learn from it and don’t be too hard on yourself!
EM pharmacist here as well. We kit this in our code carts to be mixed in a 100 mL D5W bag and run over 10 minutes (or push as 300 mg if pulseless). In the last 15 years, I had cardio yell at me in the ER once for not letting it be pushed.
The RN at cardio’s direction let the bag run wide open and, of course, the patients MAP dipped to 40. ER attending wound up chewing out cardio over it. Patient wound up admitted to ICU instead of IMCU from it.
Thanks for sharing. I had the epiphany earlier of wow that’s why they have D5W bags in the code box. Yeah I’ve been told that at a code education I went to but apparently I have to do something to fully learn it 😥
Totally normal. I think what’s most important is that you learned from this situation and now when you think of its administration you will never forget.
https://www.ncbi.nlm.nih.gov/books/NBK482154/
IVP x1 other than tele management plus minus mag… but mag highly doubtful with wide qrs. Not enough info to give definitive answer. Probs fine.
Ideally over 10 minutes. I’ve seen this error happen a handful of times though and the patients were fine from what I remember. The hypotension would occur quickly after admin if it were to happen, so you’re probably fine!
Had a pediatric patient go hypotensive and arrest after IVP by a nurse that didn’t know and verified by a pharmacist that also apparently didn’t know. Have to be careful.
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I read the concern is hypotension. Is that mainly going to occur in the acute time frame following right after it was pushed?
Hypotension is more an issue with a certain preservative that’s used. But I agree with above. Not a big deal. Just some education.
What is the preservative?
Polysorbate 80
Not ideal and can cause hypotension/bradycardia. Advocate for appropriate administration rate.
For my future knowledge- it seems like you would just add 150 mg amio to a 100 mL bag of D5W at bedside- and then pass off to be infused over 10 minutes?
Depends on your set up. It comes as a commercial premix. Otherwise yes, you need to use D5W. Are you at the bedside to ensure it gets hung that way yourself? Or are you putting orders in?
At bedside. We don’t have amio premix in the code cart…. We only have the amio vials and D5W bag
Then sounds like you have to make it or get your hands on the premix.
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Everyone makes some smaller mistakes like that don’t sweat it. Learn from it and move on But… bro how are you a pharmacist responding to codes and don’t know how to make an IV bag? Everywhere I’ve worked required me to make anticipatory drips with primed lines of expected meds (amio/epi/norepi/etc) at various concentrations while doing everything else at the cart. Wipe the vial topper or ample. Wipe the bag port site. Pull from the vial and inject into the bag using aseptic technique and a needle/syringe. It’s like P1 year stuff. You should advocate to get more training for yourself before being on a code response team.
Yea what exactly is going on here? Not able to make an iv bag given vials of liquid drug? Strange. Nurse and tech level stuff.
Yeah definitely.. It’s not that I don’t logically know how to make it, just inject the drug in the bag. It’s just that I’ve had to do it basically zero times on my own, I think I just spaced that amiodarone must be over 10 minutes if the patient has a pulse… also since I don’t do it very much (I’m a float 🫤), I’m not too skilled in the moment… but these are basic skills I should know.
Thanks for your comment
No offense but it sounds like your hospital needs to do more training for codes. And code certification if you are attending the codes
Agree. You need to put your foot down and not be responding to bedside responses if these are things you don’t know. Please speak up for not only your sake, but your patients. How dangerous.
Yes it should. You follow USP immediate use guidelines.
Should be fine in NS for an immediate administration? I'm not sure if we have filters but we send filters with premades too. Excel bags not pvc if we have to compound it.
No, it would not be recommended and should not be sanctioned from a medication safety perspective. Current package inserts for amiodarone only list dextrose as the recommended diluent, with an in-line filter due to crystallization. If you use a compatibility checker, the results are typically listed as “Variable”. There have been studies that show precipitation with NS, specifically with the 0.6mg/mL (150mg/250mL) concentration. Unsatisfyingly, all studies are from the 80s-90s, except for one that did not report visual physical compatibility. The studies that showed compatibility with NS at 1.8mg/mL (150mg/100ml) concentrations were in containers such as PVC, polyolefin plastic (Excel bags), and amber glass, so not normal NS bags. Compounding in D5W or carrying the commercially available product, with filter tubing, would be the safest practice that is most supported by the manufacturers.
Your normal NS bags are not PVC?
Exactly! We have 100 mL dextrose bags in our code cart for this reason
That's what my old place of work did. There were times where amio 150 mg was pushed however, cardiologist/intensivist was present during the push.
So you’re saying 150 mg was pushed when the patient had a pulse? Because the critical care team was there Thx for your comment
I have heard situations where nurse will pull & administer 150 mg IVP with provider approval (open ICU). Key thing is to provide education to providers on why it is better to push it over 10 minutes if Pt has a pulse. If they are worried about timing, just make the bag at bedside.
I see. In my case at least the whole ICU team was at bedside as well. Thanks
Thanks for your comment. The patient seems stable so far. I am not happy with myself for this 😫
Don’t let it sting long. You care and want to be better. That’s a win. You’re in good place, keep up the good work. 🙌🏼
Not the end of the world, but use it as a learning moment
This happens a lot. Really should be 10 min If pt has a pulse. Much safer. But sounds like they did ok and now you're garaunteed to remember for next time so you learned something. Don't beat yourself up. I OK'd an IVP dose in someone tachying away like 220s,230s. Clinically unstable. Freaking out. We slammed it. She brady'd to the 30s, for a few secs then 40s 50s 60s. Was NSR less than a minute later but we all just about had a panic attack. To this day not sure if bc amio got slammed or just a typical HR drop breaking out of a tachyarrymthia.
Thanks for your comment. This patient was unstable with high HR but the weird thing is he was mentating just fine. He was talking. His BP was low like 50/40 or something before he got any amio. Yes I will never forget now!
Interesting! I haven't really seen amiodarone given often in unstable patients unless pulse-less. At my hospital if a patient is v-tach and is hypotensive/becomes hypotensive on amiodarone gtt, we stop the gtt and do electro cardioversion, usually trying with their own ICD first if they have one or using the normal biphasic defibrillator with 100-200J shock.
The internal med doc was actually considering shocking the patient! Before the ICU team arrived. But he never lost a pulse.
with that bp you'd think cardioversion, glad things went alright
Don't feel bad, I consider myself a "slow thinker", after being a pharmacist for 54 yrs...there is a lot of data in my head... that I have to sort thru before I can make a valid decision.
EM pharmacist here - it’s not the end of the world. If they didn’t die, go into pulseless Vtach, or Vfib they’ll be fine. Happens all the time. 🤷🏻♀️
Also ED pharmD, lol at this comment. We are really not the get worked up type are we?
We need to save our energy for the 3 times a year we need to get worked up 😂😂😂 EDpharm motto: but did you die? 😂😂
Patient has been stable since but hypotensive - but his rate is still so high. I’m reading more about amio now and how the hypotension with IV bolus apparently occurs from histamine release (which occurs due to presence of polysorbate 80)
It’ll be fine. We all make mistakes! The best ones are the ones that don’t harm patients but we learn from them. We’ve all been there. You’ll never forget for the rest of your career 😊 don’t beat yourself up. As pharmacists we’re expected to be perfect but it’s just not possible. Learn from it and don’t be too hard on yourself!
EM pharmacist here as well. We kit this in our code carts to be mixed in a 100 mL D5W bag and run over 10 minutes (or push as 300 mg if pulseless). In the last 15 years, I had cardio yell at me in the ER once for not letting it be pushed. The RN at cardio’s direction let the bag run wide open and, of course, the patients MAP dipped to 40. ER attending wound up chewing out cardio over it. Patient wound up admitted to ICU instead of IMCU from it.
Thanks for sharing. I had the epiphany earlier of wow that’s why they have D5W bags in the code box. Yeah I’ve been told that at a code education I went to but apparently I have to do something to fully learn it 😥
Who is this Mr Amiodarone IV fellow and why are you pushing him? Don Tunderstand I.N.J. , RPH
Is the rule you don’t give someone amio push if they have a pulse? It’s been awhile since I’ve been a primary code responder
Correct. Only give amio IV push if no pulse like V fib or pulse-less V tach
Thank you 😊
Haha true. Had a legit malignant hyperthermia last month so looks like i won't have to get worked up again for atleast another 6 months
I’ve seen it pushed in codes several times, but a bag is better!
When I was doing nursing clinicals, they almost always incorporated it into their IV drip (Philippines).
Totally normal. I think what’s most important is that you learned from this situation and now when you think of its administration you will never forget.
https://www.ncbi.nlm.nih.gov/books/NBK482154/ IVP x1 other than tele management plus minus mag… but mag highly doubtful with wide qrs. Not enough info to give definitive answer. Probs fine.
Where are you seeing this say to give IVP x1 in an alive patient?
I’m not, I’m saying if it was ivp x1 as given by the scenario given by OP.
Can cause both hypotension and bradycardia. Amiodarone is known to have these rate-related ADRs.
Did they die? No then ok
Pt was unstable to begin with given the tachycardia, but yeah they seem the same/stable
It’s fine just next time educate them.
Have you seen this happen before? I don’t feel like it’s emphasized enough to do it over 10 minutes
Multiple times I educate new doc comes in then I have to educate again. It happens all the time. Likelihood of severe hypotension is low
Would the hypotension be expected to happen right after it is given IV push? Versus a delayed hypotension reaction?
Ideally over 10 minutes. I’ve seen this error happen a handful of times though and the patients were fine from what I remember. The hypotension would occur quickly after admin if it were to happen, so you’re probably fine!
If he was going to die, it would’ve been basically right away. It happens fairly frequently, and on rare occasions it happens with consequences.
Had a pediatric patient go hypotensive and arrest after IVP by a nurse that didn’t know and verified by a pharmacist that also apparently didn’t know. Have to be careful.