Episode 533: Three tips for inpatient medical emergencies

In this episode, I’ll discuss three tips for inpatient medical emergencies.

Tip #1: ACE Inhibitor-Induced Angioedema

When taking care of a patient with ACE inhibitor-induced angioedema, I focus on helping to facilitate protecting the patient’s airway with intubation.

I don’t get distracted by other therapies which do not have a clinically meaningful effect:

Epinephrine doesn’t work in ACE inhibitor-induced angioedema.

Neither does diphenhydramine, methylprednisolone or ecallantide.

Fresh frozen plasma might help – but you need to thaw it first… and that takes too much time to be practical.

Icatibant only affects meaningless endpoints like edema, not the need for intubation or mortality.

Tip #2: Lipid Rescue Dose

When lipid emulsion is used as an antidote for enteral drug toxicity, the American College of Medical Toxicology recommends a 10-fold reduction in the maintenance infusion of ILE after the first few minutes, compared with when it is used for local anesthetic toxicity.

There are several good reasons for reducing the maintenance infusion rate:

1.  There is a case report of ILE clogging CRRT filters, possibly contributing to a patient’s death.
2.  Acute respiratory distress syndrome and ventilation/perfusion mismatch have also been reported in patients who have received traditional ILE dosing for drug toxicity
3.   A physiologically based pharmacokinetic-pharmacodynamic model suggests that the reduced maintenance infusion rate is sufficient to produce a plasma triglyceride concentration that will provide the scavenging and cardiotonic benefits of ILE.
4. This model is supported by two case reports where a lower ILE maintenance infusion rate was used successfully: case one & case two.

Tip #3: IV Compatibility

When a patient is unstable or ‘crashing’ the team usually doesn’t feel like the time it takes to check IV compatibility is worth delaying treatment to a patient. That’s why I keep in mind two basic IV compatibility rules for common critical medications that hold up according to Y-site compatibility data from Trissel’s.

Rule #1: With the exception of propofol and vasopressin (which have never been tested together) all the usual sedatives and vasopressors are compatible with each other at Y-site. This includes norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, fentanyl, midazolam, propofol, and dexmedetomidine.

Rule #2: When adding sodium bicarbonate to sedatives and vasopressors, care must be used to avoid incompatibilities. Sodium bicarbonate at Y-site is not compatible with midazolam, and it inactivates catecholamine based vasopressors such as norepinephrine, epinephrine, and dopamine. Sodium bicarbonate is compatible with fentanyl, propofol, dexmedetomidine, phenylephrine, and vasopressin.

To get a copy of 6 more tips for pharmacists responding to inpatient medical emergencies, go to my free download area. It’s number 16 on the list.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

 

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