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Lin Sessions - PO vs IV Clindamycin - Dirty Epi Drip - Propofol for Migraines

Michelle Lin, MD and Zlatan Coralic, PharmD
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EM:RAP 2014 January - Summary 1 MB - PDF

Raise your hand if you like spreading MRSA. Ok, then stop sending patients home with 1 dose of vancomycin. Michelle and Zlatan explain why and tell you how to Macgyver an epi drip with nothing but epinephrine, an IV bag, and some sort of medical device that measures exact amounts. Plus, got a migraine? Propofol!

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Shirin M., M.D. -

Here, "way up north", in Canada, we don't have a high rate of MRSA--yet; I frequently give patients a gm of Ceftriaxone IV and send them home with po Keflex--Is that also an overkill?

David W. -

I respect and appreciate the information presented in all of the EMRAP materials, but I have to question the math used in the reference to the 'dirty Epi'.

If I understood the presentation correctly, the presenter advocated using either 1:1000 or 1:10,000 epi., putting it in a 1000cc NS bag (shaken not stirred) and it didn't matter, the result would be 1ug/ml.

I need someone to double check my brain pan and the math that is coming out of it.

Although there is, indeed, 1mg of epi going into the 1000cc NS bag, the concentration of the epinephrine being introduced is different.

By mixing a 1:1000 ampule of epinephrine into 1000cc NS the concentration is then 1:1,000,000. (1ug/ml). By mixing a pre-load of 1:10,000 into a 1000cc bag of NS the concentration is then 1:10,000,000.

Does this not mean that it is no longer 1 ug/ml as the pre-load is already concentration diluted by a factor of 10?

Just a thought on potential accuracy issues.

Larry B., M.D. -

About 10 years ago I was working in a low volume ED and a patient presented asking for propofol for her headache. I had no other patients, so was able to sit at the bedside with an O2 sat monitor and slowly push a total of 400 mg propofol over an hour. When the patient awoke, she thought she still had her headache until I explained how much medicine she had received, at which point she decided she was better after all. In other words, I think some of our patients are used to the narcotic rush, and are reluctant to claim relief until they have had narcotics, but IV propofol might be a good way to separate out those with true migraines from those who are drug seekers. However, it can be extremely time and resource demanding, and I usually have good results from the easier to give Toradol, Benadryl, and Reglan or Compazine combo.

Sean G., M.D. -

The "dirty Epi" I love it! Cool, practical and FINALLY someone made an epi drip easy(no offense Mel but even you have admitted you have struggled with this!). Its cool and my wife will wonder if I'm doing something salacious at work when I tell her I did the "dirty epi" with a couple of nurses....may add a little spice to my otherwise pedestrian monogamous relationship as well as help my patients! Man EMRAP is the schiznit.....

Michelle Lin, MD -

Happy new year everyone!

@Shirin: Giving both a first (keflex) and third (ceftriaxone) generation cephalosporin indeed seems a bit overkill for me. For the sake of antibiotic stewardship, you can consider just giving keflex alone because of its great bioavailability alone. If you REALLY want to give an IV dose beforehand, would give IV cephazolin (first generation) instead.

@David W: Good questions about the dirty epi calculation. I think the factor that is missing is the fact that the 1:1000 vial is 1 cc and the 1:10000 vial is 10 cc. So both vials, whichever you use, have 1 mg of epinephrine. That's the beauty of the epinephrine. Thanks for doublechecking our math!

@Larry B: Interesting - thanks for sharing your experience with propofol. Interesting finding with your patient. I agree, I'm also still a fan of a non-narcotic concoction. I personally use toradol, compazine +/- benadryl. I'm not ready to implement a resource-intensive propofol regimen. It should be considered only for the really really really refractory case on a case-by-case basis weighing the pros/cons.

@Sean G: Glad you like this trick. It's a great one by Zlatan Coralic ("Z"). Thanks for commenting.

Sean G., M.D. -

Propofol for migraines......had to comment. I have been saying to my collegeues since the late 90's we have a Rx drug addiction problem, and the ED is on the forefront. For years I had to deal with CME after CME (many right here on emrap) telling me I was under treating pain in my ED(supposedly all of us were). That the 25 y/o with chronic back pain presenting to my ED at 3 am because his dog ate his bottle of 100ct 30mg oxycodone tabs and his neurosurgeon was in Pakistan for the next month was going to be legit 99.5% of the time, and we should err on the side of medicating the pts pain because it was the vast minority of pts that were addicted or "drug seeking". Well frankly I have been saying this was bull for years. I believe since there have been several mainstream media documentaries exposing just how out of hand Rx narcotic abuse has become even Jim Duschwam(?sp) will have to take a step back and acknowledge its not normal for most of my 10 year old pts to know what vicodin is as they unfortunately do. Propofol is a highly addictive drug and is now being made in underground labs. I have seen a rise in pts seeking propofol in the ED they will present with a recurrent dislocation and insist only propofol works....I have been told by them on occassion(while under the influence of propofol) that they have gotten it on the streets. Please lets not go there.

Brent T. -

@David W - as Michelle noted, the bottom line is that there is 1mg of epi in approximately 1L of fluid. I think the math should look like this:

1:1000 epi = 1mg/1mL. When added to 1L you get 1mg in 1001mL. To be exact that is 1:1,001,000 (rounds to 1ug/mL)

1:10000 epi = 1mg/10mL. When added to 1L you get 1mg in 1010mL. To be exact that is 1:1,010,000 (rounds to 1ug/mL)


Brent - that is Swiss precision! This original and archaic dosing drugs in % e.g. Lidocaine 1% and in 1:1000 of Epi is based on grams in liters of solutions. I.e. 1 gram of Epi in 1 Liter of D5W makes 1:1000.

For the dirty dripping of Epi, we should probably move away from calling things 1:1000 or 1:10,000 and just state the following:
1mg of Epi (regardless of solution or pre-packaged prep) and mix in 1 Liter of NS or D5W ==> 1 mcg/mL of Epi.

Zlatan C. -

Thanks for all the comments and for having me on EMRAP this month!

Just to help out with the calculation of Dirty Epi. All IV bags come with overfill of about 5-10%. 1 L NS bag usually has about 60 ml overfill. Pharmacist take this into account when making drips or chemotherapy, where the drug (or patient) is concentration or volume sensitive.

If you use 1 mg/ml (1:1000) vs 1mg/10ml (1:10,000), the 10 mls are going to be negligible. Specifically 1 mcg/ml vs 0.99 mcg/ml (or 0.943 mcg/ml vs 0.935 taking into account the overfill). I stay away from converting this into ratios, as it has more potential for bedside confusion.

Remember that the dirty epi is for dire situations in a limited resource environment. There are less steps and calculations than an Epi push.

Thanks for all the feedback!

Gannon D -

I sometimes give patients 600-900mg of IV clinda prior to discharge for skin infections. Could I avoid this by just giving them 600-900mg orally? I usually give patients 300-450mg po qid when discharged.

Zlatan C. -

@ Gannon; Theoretically you could load the patient with a 600mg PO dose prior to discharge - I am just not sure if there is any clinical benefit to this approach vs. just starting the regular home regimen. Thanks for the comment!

Whit F., M.D. -

Hi Zlatan and Michelle - Whit here!

One thing I run into ALL THE TIME is the patient with a terrible cellulitis or other soft tissue infection who refuses admission for IV antibiotics. Often they have some childcare issue or other pressing matter, and they absolutely won't stay. One of my old professors told me that if you give a patient a gram of probenecid po and then a nice big dose of IV beta lactam (such as unasyn), their serum levels will remain elevated for a much longer period - it's a bit like giving the patient 3 doses of IV antibiotics instead of one. The idea is that it improves the chances of 'beating' the infection, though of course you still ama them and prescribe them oral antibiotics as well. Whaddya think of this? Does it work? Is it a terrible idea? Is it safe? Can you do tricks like this with other antibiotics?

Zlatan C. -

Hi Whit! Thanks for the question.

Probenecid - the drug has been around since 1949, but everyone has forgotten about it! Unfortunately, I have no evidence for one-dose probenecid approach for SSTIs. [Ann Pharmacother. 2004 Mar;38(3):458-63] - looked at cefazolin and probenecid, but both meds were given on a daily basis.

Theoretically, with one slug of probenecid the half-life of beta-lactam antibiotics will be extended for 1, maybe 2 days - probably not long enough to provide adequate coverage.

There is a new drug on the horizon and pharma will start targeting ED docs heavily soon - dalbavancin (no conflict of interest). The sales pitch is the duration of action: 1 week after one IV dose for SSTIs. Equivalent spectrum to vancomycin, including MRSA. It could be useful in patient population you describe, but not for most patients who are willing to take cheap oral meds which are just as efficacious.

Thanks for listening!

Michael L., M.D. -

Dear Zlatan and Michelle,

Thanks so much for the session. Just a question: It seems as though every time Epi concentration comes up, the answer is: it doesn't really matter as long as the same total amt (mg's) is given.

In terms of drips, it would seem that decreasing the volume (say, putting 1mg into 500cc bag), would double the concentration, but again, as long as equivalent amts of epi was given (in this case half the # cc's), the only difference here is volume. So in a pt with severe systolic congestive heart failure for example, you may wanna put 1 mg in 500 cc's in order to give the same amount of Epi with a smaller volume.

But having said all this, it makes me wonder then why do we have a distinction and why was it so pounded into our heads w/ACLS-- why is the "code concentration" 1:10,000.(10mls)? Can't we as easily just give 1:1000 concentration (1ml) ? The same amt, 1mg, would be given in both cases. I always assumed it was bc there is a distinction between giving a push-dose (vs a drip), in terms of the higher concentration (1:1000), "hitting harder" bc it is less dilute. If this is simply not true, it makes no sense why the ACLS code concentration can't just as easily be 1:1000 (1mL), saving all sorts of confusion and med administration error.

Thanks so much in advance for your time.

Zlatan C. -

Hi Michael, thanks for the feedback!

You are absolutely correct, epi drips can be concentrated for patients who are sensitive to fluid overload. For example, we concentrate the epi drips to 8mg/250ml. Yes, 8 mg in a small bag!

The problem with concentrating epi drips bedside in the ED is two fold - it confuses everyone on how much to shoot into the bag; and then, calculating the drip rate, especially if you work in a setting where there are no smart-pumps capable of controlling the infusion rate. The chances of making an error would be pretty high. If the patient is "stable," I always rely on getting a standardized concentrated drip from pharmacy.

The dirty epi we talk about in the podcast is the simplest way to make an epi drip in a high stress situation with virtually no resources (i.e. unknown hospital standards for making drips, staff shortages).

The 1:1000 epi concentration is very very very concentrated. One reason we do not push 1:1000 IV is that it is so potent and vasoactive, and if given IV there is a good chance you would blow the line and cause extravasation & tissue necrosis. Simply too potent to be given peripherally. If given via central line, I'd be worried about myocardial ischemia / stroke due to vasospasm. If you get a chance to comb through literature, there are many horror cases with 1:1,000 epi being inadvertently administered IV. Scary stuff.

Thanks for the feedback!

Michael A., MD -

CA-MRSA has a readily inducible resistance to Clindamycin, so although acceptable, Doxycycline/Minocycline and Trimethaprim-Sulfamethoxazole are recommended for MRSA, so try and save the Clindamycin.
Clinda can cover the Strep species as well as MSSA/MRSA so if uncertainty for which Gm positive you have, Clinda can be used, but again an alternative is a Beta-Lactam with either of the Doxy/Mino or TMP-SMZ.
Just some thoughts from the east coast of Canada

Whit F., M.D. -

Michael A. - I loved minocycline because it apparently covers c-MRSA and strep (at least in Sanford), but a dermatologist told me it doesn't really do the job with strep. What do you think?

Zlatan - I agree that the "probenecid boost" isn't a justifiable standard-of-care trick. It's ONLY helpful for AMA cases, where you only have the option of either giving one dose of IV antibiotics before the patient walks out the door for good. I guess my rationale is that it's better than nothing? Of course I prescribe PO antibiotics as well.....Thanks for your expertise and thoughts!

David L. -

I agree. In my "n" of several hundred, I have NEVER had a patient not get better with an phenothiazine (compazine, reglan, or phenergan) + benadryl and IVFs. Plus, I can usually get the patient out the door within 30-45 minutes and I can leave them alone in the room to get better while I see other patients. I can see using propofol as a breakthrough treatment, but NOT as first line. It would require too much of my useful plus the ancillary staff for a "procedural sedation."

The IV vs PO clindamycin is one of my big personal downfalls. I never looked at the bioavailability of the oral, and I like having the ability to tell my patients, "I'm giving you a big gun here first before you go home." Good wake up for me, but now what am I gonna tell them.

Dottie M.D. -

Hi Michelle,

Really enjoying your sessions. Do you know how many doses of Vanco 1g q12h it would take to achieve that MIC to bacteria magic ratio of 400?


Zlatan C. -

Hi Dottie,

Great question.

The AUC/MIC for vancomycin is determinded by (total daily dose of vancomycin / clearance) / MIC of the bug. For MRSA with MIC of 1, 1g IV q8h for a 70 KG patient with normal renal function will probably be sufficient (shooting for troughs of 15-20). However, if MIC for the bug is > 1, achieving a ratio of 400 can be very challenging.

As far as how many doses of vanco - we think of at least 3-4 doses to get to steady state.


Jack G. -

I wish everyone I worked with would listen to this. I curse a bit every time a cellulitis patient comes back for repeat IV antibiotics. Time to share!!!

John U. -

After listening, I saved the dirty epi drip recipe in my phone. Just now used it on a patient who was in anaphylactic shock and unresponsive. It worked great! Awesome tool to have. Thank you.

Michelle Lin, MD -

@John U: Thanks for sharing your experience. I'll be sure to let Z know that you found his dirty epi drip helpful. Great save!

Zlatan C. -

@John U Thanks for sharing! Always great to get feedback from the front lines.

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Episode 148 Full episode audio for MD edition 251:04 min - 119 MB - M4AEM:RAP 2014 Janvier - Résumé en Français Français 42:20 min - 58 MB - MP3EM:RAP 2014 Enero - Resumen Español Español 89:14 min - 122 MB - MP3EM:RAP 2014 January - Bogan Version Australian 83:04 min - 114 MB - MP3EM:RAP 2014 January MP3 267 MB - ZIPEM:RAP 2014 January - Summary 1 MB - PDFEM:RAP 2014 January - Board Review Questions 572 KB - PDFEM:RAP 2014 January - Board Review Answers 534 KB - PDF

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