Jump to content


Photo

Lactated Ringers In Ob


  • Please log in to reply
18 replies to this topic

#1 Michael Berrier

Michael Berrier

    Advanced Member

  • Members
  • PipPipPip
  • 69 posts

Posted 27 March 2008 - 11:23 AM

One of my crews was recently chastised by the OB staff for hanging LR on a G3P2 patient presenting with preterm labor because they said they could not administer a particular medication (the crew did not remember which) if the patient had received LR. I have consulted my references and found nothing to suggest what medicine this might be.

Any help would be appreciated.
  • 0

"Anything that screws its way into the sky flies according to unnatural principles." Unknown

www.critical-caring.pro

Twitter: @Crit_Care_Excel


#2 ccflymedic

ccflymedic

    Member

  • Members
  • PipPip
  • 16 posts

Posted 27 March 2008 - 12:50 PM

IDK.. I checked with our high risk OB transport team and they stated there were no known adverse drug interactions associated with LR. Almost every one of our OB transports has LR infusing and we have no written contraindications for it besides the usual fluid overload. Im interested to know what they were referring to now also.
  • 0

#3 Mike Mims

Mike Mims

    Advanced Member

  • Moderators
  • PipPipPip
  • 1668 posts

Posted 27 March 2008 - 01:13 PM

I don't know of any "routine drugs" off-hand that's not compatable with LR.
The HTN meds and analgesics we use are compatable....
It must be a special medication or maybe a concern with the cumulative effect of the Calcium and/or Potassium in the LR vs. the side effect of an increased electrolyte levels with certain drugs??????????

We'll transport either NS or LR, even D5W1/2NS , if the pt has been NPO for awhile.
  • 0

Mike Mims

Aircare

University of Mississippi Medical Center


#4 fltpuke

fltpuke

    Advanced Member

  • Members
  • PipPipPip
  • 111 posts

Posted 27 March 2008 - 02:20 PM

I asked around our OB folks here in the O.R. and they could not give me any medications that are routinely used in obstetrics that are not compatible with LR.

I offer Methohexital as one that is incomatible, but not routinely used.........


Jeff
  • 0
Jeff G.
CRNA, MHS (EMT-P, CFRN)
And a few others that I forgot.


It is always in season for old men to learn. ~Aeschylus

#5 Michael Berrier

Michael Berrier

    Advanced Member

  • Members
  • PipPipPip
  • 69 posts

Posted 27 March 2008 - 05:01 PM

The culprit has been identified. According to the director of L&D at the receiving hospital, one particular physician uses Rocephin for patients not in active labor that present with a UTI. Google is full of references to the incompatibility of cephtriaxone and anything that contains calcium, including LR.

Anybody else run into this?
  • 0

"Anything that screws its way into the sky flies according to unnatural principles." Unknown

www.critical-caring.pro

Twitter: @Crit_Care_Excel


#6 old school

old school

    Advanced Member

  • Members
  • PipPipPip
  • 1121 posts

Posted 27 March 2008 - 06:28 PM

It sounds to me as though the OB folks just felt like giving your crew a hard time....reminds me of the cranky old ED nurses who used to refuse to use an IV that was placed prehospital.


One of my crews was recently chastised by the OB staff for hanging LR on a G3P2 patient presenting with preterm labor because they said they could not administer a particular medication (the crew did not remember which) if the patient had received LR. I have consulted my references and found nothing to suggest what medicine this might be.


  • 0
bring it in for the real thing

#7 fltpuke

fltpuke

    Advanced Member

  • Members
  • PipPipPip
  • 111 posts

Posted 27 March 2008 - 06:38 PM

The culprit has been identified. According to the director of L&D at the receiving hospital, one particular physician uses Rocephin for patients not in active labor that present with a UTI. Google is full of references to the incompatibility of cephtriaxone and anything that contains calcium, including LR.

Anybody else run into this?


WOW, talk about splttin hairs.

However, that is a real thing. I suppose he / she has a valid beef.

Jeff
  • 0
Jeff G.
CRNA, MHS (EMT-P, CFRN)
And a few others that I forgot.


It is always in season for old men to learn. ~Aeschylus

#8 JLP

JLP

    Advanced Member

  • Members
  • PipPipPip
  • 493 posts

Posted 27 March 2008 - 08:33 PM

A few months ago the FDA issued a bulletin recommending that no calcium-containing solutions be used in combination with ceftriaxone, following a couple of cases where calcium-ceftriaxone precipitates caused occurred in neonates, I believe they caused renal problems (I know this only because we had to mention it during our Provincial Lab training days).
  • 0

#9 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 27 March 2008 - 09:17 PM

Here is part of the report below

Just to be clear though, what the person said is TOTAL Bullshit. How many people are giving rocephin acutely? NONE. Switch the bag to NS is easy.



Ceftriaxone Injection (Rocephin) - Interaction with Calcium Products and New Contraindication in Hyperbilirubinemic Neonates < Print >

09/14/2007

The FDA and Roche issued an alert concerning an interaction between ceftriaxone (Rocephin) and calcium-containing products. Calcium-containing solutions are incompatible with ceftriaxone. Precipitates may form if the solutions are mixed or used concomitantly, even when administered via different infusion lines at different sites. Several neonatal deaths have been attributed to formation of these precipitates in the kidneys or lungs.

The alert also informed healthcare professionals that ceftriaxone is now contraindicated in hyperbilirubinemic neonates, especially premature infants. Ceftriaxone displaces bilirubin from serum albumin binding sites, which increases serum bilirubin concentrations and may cause bilirubin encephalopathy.

Do not reconstitute, dilute, or administer ceftriaxone with calcium-containing solutions, including Lactated Ringer's, Ringer's, Hartmann's solution, or parenteral nutrition. After ceftriaxone administration, wait at least 48 hours before administering any calcium-containing solution or product. Avoid ceftriaxone use in hyperbilirubinemic infants.

The ceftriaxone prescribing information has been updated to reflect this new information. Additional information is available at the following links:

* MedWatch alert:
http://www.fda.gov/m...07.htm#Rocephin

* Healthcare Professional Letter (June 2007):
http://www.fda.gov/m...INVANZ_DHCP.pdf

* Healthcare Professional Letter (August 2007):
http://www.fda.gov/m..._august2007.pdf

* Healthcare Professional Sheet:
http://www.fda.gov/c...ceftriaxone.htm

* Revised Prescribing Information:
http://dailymed.nlm....mp;type=display
  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#10 Michael Berrier

Michael Berrier

    Advanced Member

  • Members
  • PipPipPip
  • 69 posts

Posted 27 March 2008 - 10:43 PM

MacKinnon, et al;

BS was essentially what our medical director said with the additional thought on how easy it is to change a bag.

This has prompted a good discussion interdepartmentally and with the facility, though.

Thanks
  • 0

"Anything that screws its way into the sky flies according to unnatural principles." Unknown

www.critical-caring.pro

Twitter: @Crit_Care_Excel


#11 Will Wingfield

Will Wingfield

    Advanced Member

  • Members
  • PipPipPip
  • 334 posts

Posted 30 March 2008 - 02:36 AM

I can't WAIT to throw that one at some of my precepting CRNA's next week. Some of our surgeons use Rocephin as an up-front abx before surgery and we hang LR on everyone. heehhehhhe

WW
  • 0
William Wingfield, CRNA, MSNA, FP-C, CFRN
Owner/Educator
The ResQ Shop, LLC

#12 Michael Berrier

Michael Berrier

    Advanced Member

  • Members
  • PipPipPip
  • 69 posts

Posted 30 March 2008 - 03:09 AM

I can't WAIT to throw that one at some of my precepting CRNA's next week. Some of our surgeons use Rocephin as an up-front abx before surgery and we hang LR on everyone. heehhehhhe

WW



Will,
Definitely keep us (me) posted on that discussion. I'm in need of lots of professional opinions on this one.

Oh, and love the book, BTW.
  • 0

"Anything that screws its way into the sky flies according to unnatural principles." Unknown

www.critical-caring.pro

Twitter: @Crit_Care_Excel


#13 Michael Collins

Michael Collins

    Advanced Member

  • Members
  • PipPipPip
  • 99 posts

Posted 30 March 2008 - 08:42 AM

There may be some validity to it. As you can see from the MedWatch report, in neonates, there have been complications of Rocephin being administered within 48 hours of calcium containing solutions, so for this population, switching the bag to NS is not sufficient to avoid this complication. As these case reports are relatively new, I do not believe that it is known whether this combination is safe for the fetus in pregnancy. Calcium and Rocephin both will cross the placental barrier.

Of course, avoiding this problem is a relatively simple matter of using a different antibiotic. While it needs more frequent dosing, Claforan (cefotaxime) is a suitable replacement for Rocephin in most cases. In this particular case, both of these antibiotics are Pregnancy Category B.

Here is part of the report below

Just to be clear though, what the person said is TOTAL Bullshit. How many people are giving rocephin acutely? NONE. Switch the bag to NS is easy.



Ceftriaxone Injection (Rocephin) - Interaction with Calcium Products and New Contraindication in Hyperbilirubinemic Neonates < Print >

09/14/2007

The FDA and Roche issued an alert concerning an interaction between ceftriaxone (Rocephin) and calcium-containing products. Calcium-containing solutions are incompatible with ceftriaxone. Precipitates may form if the solutions are mixed or used concomitantly, even when administered via different infusion lines at different sites. Several neonatal deaths have been attributed to formation of these precipitates in the kidneys or lungs.

The alert also informed healthcare professionals that ceftriaxone is now contraindicated in hyperbilirubinemic neonates, especially premature infants. Ceftriaxone displaces bilirubin from serum albumin binding sites, which increases serum bilirubin concentrations and may cause bilirubin encephalopathy.

Do not reconstitute, dilute, or administer ceftriaxone with calcium-containing solutions, including Lactated Ringer's, Ringer's, Hartmann's solution, or parenteral nutrition. After ceftriaxone administration, wait at least 48 hours before administering any calcium-containing solution or product. Avoid ceftriaxone use in hyperbilirubinemic infants.

The ceftriaxone prescribing information has been updated to reflect this new information. Additional information is available at the following links:

* MedWatch alert:
http://www.fda.gov/m...07.htm#Rocephin

* Healthcare Professional Letter (June 2007):
http://www.fda.gov/m...INVANZ_DHCP.pdf

* Healthcare Professional Letter (August 2007):
http://www.fda.gov/m..._august2007.pdf

* Healthcare Professional Sheet:
http://www.fda.gov/c...ceftriaxone.htm

* Revised Prescribing Information:
http://dailymed.nlm....mp;type=display


  • 0

#14 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 30 March 2008 - 01:58 PM

Hey

Well fishbowl kids are a whole seperate category. There should be no issue in the pregnant patients with switching the bag simply because of the volume of distribution the LR will have already become apart of. The additional Ca will be physiologically irrelevant. It only matters when they are administered together from how I read those articles.

That make sense?

There may be some validity to it. As you can see from the MedWatch report, in neonates, there have been complications of Rocephin being administered within 48 hours of calcium containing solutions, so for this population, switching the bag to NS is not sufficient to avoid this complication. As these case reports are relatively new, I do not believe that it is known whether this combination is safe for the fetus in pregnancy. Calcium and Rocephin both will cross the placental barrier.

Of course, avoiding this problem is a relatively simple matter of using a different antibiotic. While it needs more frequent dosing, Claforan (cefotaxime) is a suitable replacement for Rocephin in most cases. In this particular case, both of these antibiotics are Pregnancy Category B.


  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#15 Michael Collins

Michael Collins

    Advanced Member

  • Members
  • PipPipPip
  • 99 posts

Posted 30 March 2008 - 08:56 PM

I maintain that a reasonable argument can be made that while safe for the mother, the combination, even if separated in time or volume, may be unsafe for the fetus.

Hey

Well fishbowl kids are a whole seperate category. There should be no issue in the pregnant patients with switching the bag simply because of the volume of distribution the LR will have already become apart of. The additional Ca will be physiologically irrelevant. It only matters when they are administered together from how I read those articles.

That make sense?


  • 0

#16 MSDeltaFlt

MSDeltaFlt

    Advanced Member

  • Members
  • PipPipPip
  • 559 posts

Posted 30 March 2008 - 09:21 PM

Learn something new everyday. Interesting.
  • 0
Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#17 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 31 March 2008 - 12:52 AM

Ok

Where is the evidence then?


I maintain that a reasonable argument can be made that while safe for the mother, the combination, even if separated in time or volume, may be unsafe for the fetus.


  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#18 Michael Collins

Michael Collins

    Advanced Member

  • Members
  • PipPipPip
  • 99 posts

Posted 31 March 2008 - 01:39 AM

I will freely admit that there isn't any good evidence. Even the recommendations on MedWatch are based on a very small number of case reports, exclusively in neonates.

That having been said, the recommendation of the manufacturer (available here) is
"Rocephin and calcium-containing solutions, including continuous calcium-containing infusions such as parenteral nutrition, should not be mixed or co-administered to any patient irrespective of age, even via different infusion lines at different sites. As a further theoretical consideration and based on 5 half-lives of ceftriaxone, Rocephin and IV calcium-containing solutions should not be administered within 48 hours of each other in any patient"

If you believe that this is only a theoretical interaction in populations other than neonates, in a pregnant woman, it would still be possible to cause this interaction in the fetus since both calcium and Rocephin will cross the placenta. Again, I freely admit that I am not aware of any case reports of this.


Ok

Where is the evidence then?


  • 0

#19 Mike MacKinnon

Mike MacKinnon

    Advanced Member

  • Members
  • PipPipPip
  • 920 posts

Posted 31 March 2008 - 04:04 AM

Hey Mike

I understand what you are saying, essentially, play it safe. I dont disagree but one of the things Ive seen happen over the years is absolute BS recommendations based on medicolegal liability and not science. This is one of those.

Im not challenging you mike, just the data behind this recommendation.

Here is why:

- The ONLY study to show any relation is 9 years old.

1. Burkiewicz JS. Incompatibility of ceftriaxone sodium with lactated Ringerís injection. Am J Health-Syst Pharm 1999;56: 384.

- The entire recommendation resulted from this data:

In addition to the five post-marketing reports provided by Roche,, The FDA has received four additional post-marketing reports of interactions between ceftriaxone and calcium-containing products in patients up to one year of age since FDA first approved Rocephin in 1984. Three of the interactions resulted in death; in one instance the patient was receiving parenteral nutrition. An autopsy in one patient revealed evidence of crystals in the lungs.

So in 28 years TWENTY EIGHT YEARS, of giving rocephin with LR (which is not at all unusual), there have been 9 interactions in neonates. Thats not reliable data whatsoever to make a sweeping scientifically based recommendation for adults pregnant or not. Literally tens of millions of people have gotten LR & rocephin (pregnant ones) yet not one documented issue, let alone all the neos and adults who also have.

- "There are no data on interactions between intravenous ceftriaxone and oral calcium-containing products or between intramuscular ceftriaxone and intravenous or oral calcium-containing products."

This is a perfect example of changing drug rules based on statistical outliers and medicolegal liability. The same thing happened with the black boxing of inapsine and demerol.
  • 0
Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain