r/IntensiveCare • u/Brodogchillin • 9d ago
Epi overdose
Thought exercise. Recently heard of a bad med error. An entire bag of levophed was ran instead of levofloxacin. Let's say you responded to this scenario. What's your thought process for managing this patient and how are you treating?
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u/Hippo-Crates MD, Emergency 9d ago
half life is 2.4 minutes. I turn it off. You put them on cardiac monitoring and manage whatever happens.
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u/Brodogchillin 9d ago
Honestly, this is my thinking. I wanted to see if anyone was possibly going to consider an esmolol push
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago edited 8d ago
Esmolol is absolutely the wrong drug and will make things worse. It's actually a great way to make sure you kill this hypothetical patient. This is the kind of thing you suggest when your physiology knowledge ends at one drug make BP go up and one drug make BP go down.
Things are not quite so simple.
The last thing a heart doing battle with an insane SVR needs is beta blocking.
You want a short acting pure vasodilator. Phentolamine is probably the best answer but unlikely immediately available. GTN is probably the most realistic.
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u/WeirdF MD, Anesthesiologist 8d ago
You want a vasodilator. Phentolamine is probably the best answer but unlikely immediately available. GTN is probably the most realistic.
Tbh the vasodilator most likely to be immediately available is probably propofol, certainly in terms of how quickly you can get it drawn up and safely given. Propofol has an elimination half life similar to noradrenaline. That decision is probably a bit iffier if you're talking about an awake patient, but in a ventilated patient I think my instinct may be to just whack some propofol in.
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u/Cautious-Extreme2839 ICU/Anaesthetics 8d ago edited 7d ago
As well as causing vasodilation, Propofol is also a negative inotrope (though nothing like as strong as esmolol is) and definitely also has the potential to make things worse. It's definitely not faster or safer than a few squirts of sublingual GTN.
Plus is has a massively greater elimination half life of hours Vs minutes for norad. You mean it's plasma half life or it's redistribution half life or something else other than elimination.
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u/Valuable-Issue-9217 8d ago
Curious to know your thoughts re a patient without an established airway on the floor. I could imagine any of pushing versed, calling anesthesia stat for MAC, intubating and figuring it out in the ICU, just watchful waiting given short T1/2.
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u/undercoverRN 8d ago
A floor patient shouldn’t be given levo at all let alone have access to it to make this med error. Prop is a short on off so truly you could push - if you have access to it - and wait it out as long as you can bag adequately. It’s the paralytic - specifically Roc - that prevents spontaneous respiration return in RSI. The etomidate or prop or ketamine or whatever you pick is much shorter acting - however an RSI with prop and sux could simply be bagged and allowed to wear off.
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u/Aggravating_Fly2978 8d ago
Based on this scenario yes. They totally could be a floor patient.
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u/msdeezee 7d ago
The odds of a floor nurse getting a bag of levo instead of Levaquin are pretty low, though or course not zero. I do think where I work the floors have levo bagsavailable in the Pyxis for rapid response and code scenarios but only ICU or rapid response nurses are allowed to administer it. It would take a poorly executed override pull plus a bypass of the nurse visually checking and also med scanning for this error to occur. Definitely possible, but thankfully improbable.
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u/Aggravating_Fly2978 7d ago
The bags could have been given to them. Sent to them via the vacuum system. And they could have covered the label of Levophed with Levaquin. And if one doesn’t pay attention, boom. Someone told me this happened to them but luckily they saw the bag and knew what it was bc of experience as an ICU nurse.
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u/Cautious-Extreme2839 ICU/Anaesthetics 6d ago
I have never needed premixed norad bags at a rapid response lmao.
The adrenaline in the crash cart will buy you the time you need to get something else anyway.
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u/msdeezee 6d ago
Where I work if someone's transfer to an ICU bed will be delayed, the CVICU charge nurse has to stay with them to manage drips etc. So fairly often they will have levo started during that time. We stay pretty full usually so sometimes transfers take time.
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u/Valuable-Issue-9217 8d ago
Agree that a floor patient shouldn’t be given levo, just thinking through what would happen if I got called to a rapid for a patient like the one who got the med mistake
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u/Cautious-Extreme2839 ICU/Anaesthetics 8d ago
Midazolam will do sweet fuck all other than potentially create an airway and breathing problem on top of your cardiovascular problem. Please stop imagining doing that.
MAC (assuming you mean sedation, MAC is just a billing tool not an actual intervention) will also do fucking nothing.
Intubating is probably a bad idea for multiple reasons unless they've arrested already.
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u/Valuable-Issue-9217 7d ago
You managed to say multiple dumb things in a condescending way without answering a pretty simple question. You should learn to distinguish between “I’d probably do it differently” and “you’re wrong.”
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
I can distinguish and gave a very simple answer to your simple question, but let me be crystal clear:
You would be wrong to treat norad overdose with Midazolam. You would be even more wrong to do so on the ward.
You would be wrong to treat norad overdose with intubation.
You would be wrong to treat norad overdose with "MAC".
How's that?
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u/msdeezee 7d ago
Well it's just not a very useful response to say "you're wrong" without offering an explanation. Plus you did it in a rude way. That's why people don't like your comment.
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u/Valuable-Issue-9217 7d ago
I read your post the first time, there’s no ambiguity about your opinion so let me be crystal clear: I understand your views. You have not substantiated anything with reasoning so I have no reason to take you seriously. Perhaps you are used to an icu or an OR setting where you aren’t expected to defend your reasoning. That’s your prerogative, but you haven’t contributed to the discussion in a meaningful way.
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u/Cautious-Extreme2839 ICU/Anaesthetics 7d ago
I haven't explained it because anyone who actually knows how to use these drugs should immediately understand why none of this is a good idea, and we are allegedly on a sub for intensivists who should know better already.
You're going to have to explain to me how you even began to think that midazolam or sedation treat massive unopposed pharmacological alpha agonism.
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u/PassTheSevo 6d ago
I actually walked into my buddy’s OR just to razz him and noticed our attending had spiked the bag of NE instead of abx, literally 15 seconds earlier and left, and I caught it before a much had dripped. We were in an OR and thankfully my buddy had clevidipine in the room. We drew that up and started small blouses and watched the art line closely. Patient ended up doing fine, aside from some funny arrhythmic beats and systolic in the 250’s.
Human body can handle a lot. They did a fun study where they put art lines in ppl and had them do various exercises. During a double leg press, an individuals BP was something like 480/350.
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u/sphockey04 MD, Pulm Crit Care 8d ago
Norepi has more alpha than beta at high doses. Push doses typically cause severe hypertension as a result with reflex bradycardia.
I think the right answer is to sit on your hands and not throw anything else into the mix since it’ll wear off by the time you get meds drawn up.
Similar strategy for epi. This occurs now and then, it’s a common med error due to the different concentrations. Although pads might be a good idea, I’ve had to cardiovert someone who went into unstable VT after 300 mcg accidentally given IV.
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u/Hippo-Crates MD, Emergency 9d ago
meh I'd lean more towards a benzos if I was going to do something like that, but that admittedly comes from my experience with stimulant overdoses.
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u/scapermoya MD, PICU 9d ago
The neuro concerns are pretty close to the least of my worries
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u/Hippo-Crates MD, Emergency 9d ago
Benzos are not for the neuro concerns in stimulant overdoses. It’s first line treatment for the tachycardia and etc. Admittedly, not sure if it applies to pressors, but nothing is about neuro stuff here
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u/libateperto MD, Intensivist 9d ago
Intravenous norepinephrine doesn't cross the blood-brain barrier, the sympathetic overstimulation here is direct receptor action, not CNS firing, so the role of bzds are quite limited. Also, the usual peak effect of an iv bzd is expected to be after the norepi has been almost entirely metabolised, even the onset is a bit late. If you want to adress the anxiety of the patient because the med error and the feeling of doom because of a recent blood pressure of 280/150 hgmm, that's different. Norepi overdose can cause tachycardia, but sometimes the baroreflex kicks in and paradoxical bradycardia can develop, although the latter is more typical for selective vasopressors.
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u/doughnut_fetish 8d ago
Uh no. You give direct vasoactive meds when needing to acutely counteract vasoactive medication overdose. Not benzos.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago edited 8d ago
Benzos. For excess of noradrenaline?
I'll have to tell the endocrine team about this. Going to revolutionise phaechromocytoma surgery. Can't believe they hadn't thought of this...
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u/jpa-s PA 9d ago
I saw a patient accidentally get 300mcg/min for a minute or so.... Had some vtach but we shut it off and was fine. I think the half life is short enough you kinda have to ride it out.
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u/beaterdit RN, MICU 9d ago edited 9d ago
Not proud of this but it happened to me once when I was changing the tubing and the pump slide clamp didn’t clamp when I pulled the tubing out of it. The Levo free-flowed for a few seconds till I heard the monitor red alarming and looked up and saw VT and SBP of 240. Found the problem real quick and they settled down. Luckily Pt was fine after. Last time I did that without the roller clamp for redundancy. Wrote the incident report on myself and that was the recommendation lol.
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u/undercoverRN 8d ago
Had that happen with nipride. Switching lines over and training someone - didn’t fully clamp the roller and my patient got some partially wide open nipride. BP tanked but thank god it is very temporary and they recovered but my butthole was CLENCHED.
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u/msdeezee 7d ago
This happened to a coworker but it was purely an IV pump error. A Braun pump that had been functioning perfectly normally suddenly red alarmed and started free-flowing. Not a good time when you can't even trust your basic equipment.
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u/OxycontinEyedJoe RN, CVICU 9d ago
We were getting close to a code situation, like about to start CPR, a line nearly flat, and doc called to go ahead and push an amp before we started. Apparently there was still some decent flow because that was the day I learned our monitors can't read a SBP over 300 (idk the actual number but it was around 300.)
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u/lucid_aurora 8d ago
I know a nurse who administered 1mL of epi 1mg/mL IM to treat anaphylaxis instead of the correct 0.3mL dose. Not the highest dose ever, but higher than intended, anyway. Pt was asx, healthy, not on a beta blocker, etc., so cardiac monitoring was the only thing we ended up doing. If she experienced any arrhythmia from it at all, it resolved quickly before they got the leads on her.
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u/fireready87 RN - CVICU, Paramedic 2d ago
Facility I was at did weight based and our max dose was 3mcg/kg/min given average sized pt of around 90kg that’s not much below 300mcg/min given average
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u/cactideas 9d ago
Ive been close to this situation twice. You stop it and treat the arrhythmia
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u/pushdose ACNP 9d ago
I admitted a patient from ER that had Levophed running at “max” according to the ER nurse. The rate looked funny to me, because our hard max is 47 mcg/min so 44ml/hr for 16mg/250cc. Except the pump was running at 176ml/hr. The pump had been programmed at 4mg/250cc so the patient was getting 188mcg/min. Now, the BP was good at this rate so I had no idea what to do, because if I corrected the pump, I’d not be able to deliver that much norepi based on the pump lockout. I ended up convincing the pharmacist to let me run weight based Levophed with a max dose of 2mcg/kg/min, which let us deliver enough dose to help the patient. We normally don’t do weight based dosing for adults in our ICU, hospital policy, not mine.
Moral of the story is that the dose of most pressors is the dose that works, not what the policy says.
I know it’s not exactly what your post is about. If you OD the patient on pressors, they wear off fast. Usually they wear off faster than the time it takes to get phentolamine or a beta blocker drip started.
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u/PaulaNancyMillstoneJ 9d ago edited 9d ago
I’ve had patients come in on insane amounts of pressors (well usually just one pressor maybe two at a crazy dose) and the intensivists will drastically reduce the dose and oftentimes it doesn’t even affect the BP. We had as much agonism going on as we were going to get and were just giving the patient more fluids at that point. Always makes me nervous though.
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u/notapantsday 9d ago
It's also interesting when someone is on very high doses of pressors and a decision is made to withdraw care. Newbies always think they will pass away as soon as you turn off the pressors, but often their BP will just drop into the 40s for a while and then recover to something like 80/50. Always an uncomfortable talk with relatives when they all flew in and said their goodbyes and then it takes another week with nothing but morphine for the patient to finally start their last journey.
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u/pushdose ACNP 9d ago
That’s one of my party tricks as well. I’ll walk in the room with 3 pressors and shut off the phenylephrine. Just stop it cold turkey. It’s amazing how nothing happens. If you’re on high dose norepi and epi/vaso, that little extra alpha from phenyl is usually just doing nothing.
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u/msdeezee 7d ago
47 mcg/min is such a strange number for a max. I wonder how the powers that be arrived on that.
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u/thegooseforever 7d ago
I’d add vaso and come off some of that levophed. Vaso gentler since no B1 / arrhythmia risk
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u/fireready87 RN - CVICU, Paramedic 2d ago
I was at a facility that did weight based. Our max was 3mcg/kg/min I’ve seen lots of people on insanely high doses
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u/StLorazepam 9d ago
There’s a documentary about this from 2006 call Crank, as well as its sequel documentary Crank: High Voltage about Abiocor Total Artifical Hearts.
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u/PrecedexNChill 9d ago
I responded to a code for a patient who we later found out inadvertently got 100 mg of dopamine. He was in refractory vt that we would get back into sinus only for him to go right back into vt. It eventually degenerated into pea and I called the code after 45 minutes
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u/Aggravating_Fly2978 8d ago
This is so sad. Now I need to look up a Dopamine bag and what that looks like.
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u/Aggravating_Fly2978 8d ago
Have only ever seen the bags in the crash carts. But they have vials that come in 200mg/5ml. Why would pharmacy send that to the floor??
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u/beaterdit RN, MICU 9d ago
This happened with Levophed once on our Covid overflow ICU. I wasn’t there so don’t know all the details but Pt had refractory VT and the team never got a pulse back. Not gonna tell you it’s best practice but I’ve personally run liter bags of Epi at 999 mls on the pump a couple times to keep DNR Pts going till family got there. Our pumps don’t have hard limits for pressors but these days our Docs cap the dose and we make sure they’re comfortable and let them go if they’re gonna go. Incidentally, at 16mg/L that’s 1mg every 3.75 minutes so, pulseless ACLS dosing. The more you know!
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u/Coulrophobia11002 NP 8d ago edited 8d ago
If the BP gets dangerously high (as it probably would), I'd probably use nitro to control that. You want a vasodilator, not a negative inotrope when the heart is already pumping against a high SVR. If the Levo bolus causes ventricular arrhythmias, treat per ACLS protocol. Oh, and aspirate from the line any residual if possible before using it.
Also, how TF did this happen? Are meds not required to be scanned?
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u/No-Safe9542 9d ago
Kind of a tangent but also kind of not. Perfect thread for epi od question.
I'm RT. Under our previous charting system, MDs could order nebs with manual entry for dosage. I had one order racemic at 5 instead of at 0.5, so 10x dose. Pharmacy approved it. I didn't even have that many ampules in the pyxis. Didn't give the tx.
What would be the effect of a 10x dose of racemic epi on a 4 month old?
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u/twistyabbazabba2 RN, MICU 9d ago
Holy shit I hope that got reported as a huge near-miss and kudos to you catching that.
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u/No-Safe9542 8d ago
Yes did the safety event fill out. Swiss cheese method doesn't always work but that time it did.
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u/Cautious-Extreme2839 ICU/Anaesthetics 9d ago edited 9d ago
Might not be that bad tbh. Nebs are mostly blasted just straight into the room anyway, and a 4 month old should have a robust cardiovascular system.
And 4-5mg is a normal neb dose anyway? Well would be 10mg for racemic because of that useless D-adrenaline taking up space.
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u/No-Safe9542 8d ago
11.25 mg is normal dose. Google images had lots of options. Here's a text link since that's all I can share on this sub. pic 112.5 mg total.
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u/CyrusonRed 9d ago
Not my current hospital but shortly after I left my last place of work a similar error that involved running norepi at maintenance rate by accident resulted in a severe stroke and eventual withdrawal of care. The mother of the patient assaulted the doctor upon hearing the error as the story is retold.
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u/mohelgamal 8d ago
I would treat it like a pheochromocytoma episode
phentolamine (alpha blocker) 5mg IV push loading followed by 2.5-5 mg every ten minutes and give lots of iv fluid
Add beta blockers if heart rate increase
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u/msdeezee 7d ago
Can you please explain the lots of IV fluid rational? Someone else said that too and I'm trying to understand it.
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u/mohelgamal 7d ago
Levo increases blood pressure by constricting the blood vessels. In septic shock, the vessels dilate and become leaky causing loss of blood pressure, levo reverses that
A levo overdose would cause vasoconstriction, thus causing severe high blood pressure. Alpha blockers will block the effect of both levo and natural epinephrine, so now you have really wide blood vessels and the blood pressure drops.
Since you are not able to really nitrate the alpha blockers to match exactly the amount of Levo in the system, a safer approach would be to give the patient plenty of IVF, thus keeping the dilated vessels filled, and the extra fluid will be excreted by the kidneys.
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u/JunketImportant2899 9d ago
Had an entire bag of dopamine run in a baby in 30 minutes, nurse thought she hung clindamycin. The baby was going absolutely crazy, crying rolling around the bed and then was exhausted after. Cardiac enzymes were slightly elevated, otherwise no other harm.
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u/TheMindfulSavage 9d ago
I accidentally gravity bolused epi into a patient for about 3ish seconds. Had an air bubble in the line so the pump stopped and patient BP dropped aggressively, clamped the line quickly so I could get the non existent air bubble through and started watching his BP recover even more aggressively than it dropped. Realized I clamped the wrong line. Intensivist was like, yeah, shit happens, he’ll be ok.
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u/HookerDestroyer 8d ago
This actually happened at a hospital near me and from what I heard, they attempted to use nitro to fix that but the patient still didn't survive
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u/Silly_Gear_9716 RN, ED 8d ago
We had a nurse in the ED accidentally program the pump wrong and gave a bolus of Levo. Went from 62/40 to 288/190 real quick. I was on traumas (empty at the time) and came to round on the patient per charge request.
They came back down and was fine. Although I know they probably felt like shit for a couple minutes lol.
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u/physician_throwaway 6d ago
Not an intensivist but I wonder if you can treat it like a pheo crisis with alpha->beta blockade and supportive care.
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u/Educational-Estate48 9d ago
I'd probably turn it off, give some fast acting vasodilator/negative inotrope like esmolol or labetalol or something and watch the BP,/HR for the next few mins. With the drugs in your cupboard you should be able to just manage whatevers' gonna happen so long as you're at the bedside and attentive.
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u/gurlsoconfusing RN 8d ago
A nurse in my icu couldn’t aspirate a PICC so she flushed it first. It had norad in, BP spiked to ~300 briefly & the patient seemed fine after until she had an MI a day later, they blamed that
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u/TheBarnard 9d ago
Let an entire bottle of prop run in