UTSW/BioTel EMS ALERT 15-002  (PDF Here)

March 4, 2015


250 mL Normal Saline Supply Shortage –
Treatment Guidelines and Pharmacology Sheets Changes

The ongoing, nationwide shortage of 250-mL bags of Normal Saline Solution has created supply problems for some UTSW/BioTel EMS agencies. Effective immediately, 500-mL bags of Normal Saline Solution may be utilized instead. However, this substitution necessitates minor changes to several UTSW/BioTel EMS Treatment Guidelines and Pharmacology Sheets.

For all relevant changes, refer to the table below.

Critical points:

  1. Affected Treatment Guidelines:
    1. Obstetrical/Gynecological (“OB”)
    2. Respiratory Distress (Adult and Pediatric)
    3. Tachycardia – Unstable
    4. Ventricular Fibrillation/pulseless Ventricular Tachycardia
  2. Affected drugs:
    1. Magnesium Sulfate
    2. Amiodarone (drip infusion only)
    3. Vasoactive drip medications: dopamine, epinephrine, norepinephrine
  3. Drug preparation modification:
    1. Dilution of a double drug dose in a 500-mL Normal Saline bag.
    2. This results in a final concentration that is identical to that in the 250-mL dilution.
  4. Drug administration modification:
    1. For safety, half of the 500-mL drug mixture will be “wasted” prior to administration.
    2. So, the drug administration instructions for both drug dose and infusion times for the remaining 250 mL remain the same as originally specified for each condition.
    3. NOTE: the 30-minute infusion time for Magnesium Sulfate for PEDIATRIC Respiratory Distress is NOT new; it is highlighted in blue-bold font only for emphasis.
  5. These modifications may necessitate stocking of additional unit doses of these drugs on each ambulance and ALS apparatus until the 250-mL Normal Saline shortage ends.

EMS Providers should consult BioTel at any time with questions or concerns about these modified Treatment Guidelines, especially for drug doses and infusion rates, and particularly for the pediatric patient.

TG/Drug
 Page Drug Current Wording New Wording
OB
 40 Magnesium Sulfate 2 g in 250 mL NS
over 20 min		 4 g in 500 mL NS; waste 250 mL; administer remaining 250 mL over 20 min
ADULT Respiratory Distress
 47 Magnesium Sulfate X 2 2 g in 250 mL NS
over 20 min		 4 g in 500 mL NS; waste 250 mL; administer remaining 250 mL over 20 min
PEDIATRIC Respiratory Distress
 49 Magnesium Sulfate 2 g in 250 mL NS at 40 mg/kg (5 mL/kg) over 30 min; maximum dose 2 g 4 g in 500 mL NS; waste 250 mL; administer 40 mg/kg (5 mL/kg) over 30 min; maximum dose 2 g

Tachycardia –
Unstable

 61 Magnesium Sulfate 2 g in 250 mL NS
over 20 min		 4 g in 500 mL NS; waste 250 mL; administer remaining 250 mL over 20 min

Ventricular Fibrillation/
Pulseless VTach

 67 Magnesium Sulfate 2 g in 250 mL NS
over 20 min		 4 g in 500 mL NS; waste 250 mL; administer remaining 250 mL over 20 min

Amiodarone

 140 Amiodarone drip Dilute 300 mg in 250 mL NS Dilute 600 mg in 500 mL NS; waste 250 mL; contact BioTel for drip rate for remaining 250 mL
Dopamine
 147 Dopamine drip X 2
400 mg dopamine in 250 mL NS (1600 mcg/mL)		 800 mg dopamine in 500 mL NS (1600 mcg/mL); contact BioTel for drip rate for remaining 250 mL
Epinephrine
 148 Epinephrine drip There is currently no recipe for this 2 mg epinephrine 1:1000 in 500 mL NS; waste 250 mL; contact BioTel for drip rate for remaining 250 mL
Magnesium Sulfate
 158 Magnesium Sulfate X 2
2 g of magnesium sulfate in 250 mL NS		 4 g of magnesium sulfate in 500 mL NS; waste 250 mL; Adult: administer remaining 250 mL over 20 min; Pedi: contact BioTel to confirm dose and administer 40 mg/kg (5 mL/kg) over 30 min;
maximum dose 2 g
Norepinephrine
 166 Norepinephrine drip X 2 4 mg norepinephrine in
250 mL NS		 8 mg norepinephrine in 500 mL NS; waste 250 mL; contact BioTel for drip rate for remaining 250 mL