EMCrit Wee - Dirty Epi is Dumb, Mildly Messy Epi is OK! (2025)

October 10, 2024 by Scott Weingart, MD FCCM 4 Comments

So a recent paper reopened my hate on “dirty epi.” I use my buddy, Reub Strayer, as the stand-in for the dirty epi lovers as he coined the term on his EM Updates Blog post.

The Recent Study

Braham D, Adams DWS et al. Pre-hospital ‘dirty adrenaline’: A descriptive case series of patients receiving peripheral dilute adrenaline infusions in Central Australian remote nurse-led clinics prior to aeromedical retrieval [10.1111/1742-6723.14496]

Problems with Dirty Epi

Unrestrained
Unmeasured
Dilute

The study did not look at Dirty Epi, it looked at mildly-messy epi!

Mildly Messy Epi Drip

Mix the epi 1 mg (either 10 ml or 1 ml form) into 1000 ml bag of fluid (usually NS). Then put it on a PUMP!

Set the pump's ml/hr to 60 x your desired mcg/min rate (so 5 mcg/min x 60 = 300 ml/hr)

Set Volume to Be Infused (VTBI) to 1000 mls and you are good to go.

The Paper's Authors' responses to my request for more info

Hi Scott,

Many thanks for your kind words and it's a pleasure to chat with you.Dave has done a fantastic job leading thisreview and I am very excited to see some data from our corner of the world hit the internet.

My comments on your questions:

Re 1)Infusion pumps are widely availablein the remote area clinics in our catchment so drip count is onlya backup (and rarely used).I have never had to fall back to it on a casemyself. We didn't specifically collect pump vs free, and there is only one case with a free-flowing infusionclearly documented.For this n=1 subgroup:

Age 84.Indication was septic shock
They were in our “outer rim” so the clinic RAN was on their own with them for a number of hours
They went from 1mcg/ml to 3mcg/ml, reasoning not documented but with known renal disease Ipresume the consultant was limiting volume.
No complications of therapy, received 1.5L fluid in clinic.
BP 60/38 at time of commencement and 105/50 when we arrived
Weswitched themto norad for the transfer.
Survived to discharge after a 2 day ICU stay and a 6 day hospital stay. Nice work team.

I take your point about the definition of a “dirty epi” drip being free-flowing, but we have always referred to dilute adrenaline on a pump asdirty adrenaline around here.

Re 2)I don't think any doctorsin our service are worried about what cannulais used as long as the line is clearly patent.The development of the protocol provided didrequirecompromises to appease all parties.I’d hoped to demonstrate with this reviewthat line site and size don’t matter, and I am happy we've done so.

One practical realityis that the primary care nurses doing thisare oftenreally stressedwith these patients. There is lots to do and do quickly, and at best there will be 2 of them in the clinic.Their day-to-day work is notcrit care. This is usually not a 9-5 scenario so they are tired.In some cases it is the first time they've ever given adrenaline! In my opinion, all thismakes theoutcomes for this group of patientsgenuinelynoteworthy.

Kind regards,

Daniel Adams
Director | Central Australian Retrieval Service

Hi Scott

Firstly, it is a genuine honour for you to be interested in my paper. It’s my first ever publication and I’m thrilled with the level of interest it has gained.

1)Infusion pumps are used in most cases, however in some remote clinics where an infusion pump is not available the nurses are encouraged to manually calculate drip rate to ensure an accurate infusion rate.

2)The protocol was written before my time with the service, however I think the instructions of using a wide bore cannula in the ACF is based on best-guess and the potential evidence from the Loubani et al systematic review on peripheral vasopressors in 2015 which suggests adverse events appear to be associated with distal sites. Ultimately these are sick people in the middle of nowhere though, and the level of experience amongst the remote nurses is hugely varied. So any cannula they could get in is better than none, and it seems that no significant adverse events came from the smaller-bore and more distal cannulae. Keeping the current guideline regarding this is probably fair for best-practice purposes until further evidence that distal lines and small bore cannulae are / aren’t as safe as proximal large bore cannulae.

Thanks very much again, happy to answer any further questions as best I can.

EMCrit Wee - Dirty Epi is Dumb, Mildly Messy Epi is OK! (2025)

The Recent Study

Problems with Dirty Epi

Mildly Messy Epi Drip

The Paper's Authors' responses to my request for more info

Additional Posts on Dirty EPI

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