Emergency Drugs
Part of the morning ritual of a novice anaesthetist is drawing up a pristine set of emergency drugs for the day’s list. There’s something satisfying about quietly cracking ampoules of deadly drugs open and labelling the syringes ‘just right’.
And as with everything in anaesthetics, we’ve already hit a point of controversy.
Some consultants will advise you to draw up a full tray of emergency drugs for each list, while others will insist it is a waste of drugs and plastic and that you shouldn’t need them that quickly if you’re doing your job properly.
My advice?
Draw them up.
Especially as a novice.
Why?
For two main reasons:
There’s enough on your plate
The learning curve of the novice period is steep enough as it is, without the added stress of having to find, crack open, draw up and administer drugs that you really need to be giving within a minute or two. Having them sat reassuringly on your anaesthetic machine labelled at the ready was a real confidence booster for me.
You’ll use them if they’re there
If you’ve got a syringe of ephedrine drawn up and ready to go, you’re far more likely to actually use it than if it is sat in the cupboard.
Then, when you find the patient’s blood pressure just a little lower than you’re comfortable with, with a heart rate in the fifties, then giving 3 – 6mg of ephedrine is not going to do any harm, and it allows you to practice with the tools of your new trade.
It’s useful to get experience with seeing how these drugs work, and how much effect you get from a given dose. That way when you actually really do need them, you’ll be far more comfortable using them. A lot of consultants seem to take pride in not needing emergency drugs, suggesting that if your anaesthetic is good enough, then you’ll avoid having to give them.
Personally I disagree to a certain extent, particularly with vasopressors. If you’re giving someone a syringe full of propofol, causing their entire vascular system to relax, to me it makes total sense to counteract that with a little metaraminol or ephedrine just to replace some of that vascular tone – but hey – each to their own.
Standard recipe for an emergency drugs tray
METARAMINOL 0.5MG/ML
- For hypotension with a heart rate above 60bpm
- Give 1ml and assess response in 30 seconds
- If you’ve given more than 10ml in divided doses, then you should think about an infusion, and maybe even a central line and noradrenaline
EPHEDRINE 3MG/ML
- Usually comes as 30mg in a 1ml vial
- Draw up 9ml of saline into a 10ml syringe, then add your 1ml ephedrine to make 3mg/ml
- Give 1 – 3ml boluses and assess response in 30 seconds
- There’s no point giving more than 10ml in total, because it exhausts the body’s noradrenaline stores – move onto metaraminol or noradrenaline next
GLYCOPYRROLATE
- Usually comes as 200microgram/ml in either 1 or 3 ml vials
- Used to treat airway secretions (45 mins before induction ideally)
- Also used for bradycardia – generally considered more ‘gentle’ than atropine
ATROPINE
- Usually 600microgram/ml
- Used for profound bradycardia, particularly in paediatrics (20microgram/kg)
PROPOFOL
- Used for rescue sedation, in case patient wakes up agitated, bites the tube or develops laryngospasm
- 2 – 5ml bolus to re-establish control of the situation
- Often forgotten until you need it!