A few days ago I put up a thought experiment blog on generalizing the dose of rocuronium to 100 mg for anyone over the age of 18 years old. You can find that post here.
Here are my thoughts:
1. Based off height not weight.
2. Some the dosing range of Roc is very wide 0.9 to 2 mg/kg. 100mg would give 1.2 mg/kg for any male up to 6ft 2inches and 2mg/kg for some a male at 5 ft. Both of these are within acceptable dosing recommendations. Only variable is length of paralysis.
3. The argument of commonplace and laziness I can sympathize with- yet I don’t buy it. If anyone has ever watched an anesthesiologist dose medications it is anything but a perfect science. Why? Knowing how the drugs work opens up some freedom. Not recommending free lance dosing-but in some situations we are being pedantic over things that don’t matter.
4.Shock dosed higher? Yes I say double it.
5.We will lose our math skills- this is the caveman fire argument that we saw with direct vs video laryngoscopy. Psh
My wicked smart friend Joey Loehner had some fiery angst built up!
I asked him to channel it into a blog for a view from the "this is a stupid idea" vantage point.
Rebuttal to The Fixed Dose Paralytics Thought Experiment
While I rarely disagree with FOAMed’s power couple- the post this morning hits on something
that I am very passionate about.
To clarify
I am not against fixed-dose Paralytics; I am against Fixed-Dose Medicine. We are the
professionals in the world of Prehospital Medicine, and the continual dumbing down of what we
do is the biggest danger to our profession and our patients.
*The obvious caveat to weight-based dosing are meds such as ASA, Nitro, etc., that only come
in one preparation*
Reasoning
The rationale for always dosing based on weight is many-pronged. First, it is the
most accurate dose for the actual patient in front of you. Second, it keeps your med math skills
strong. Third, it narrows the difference between the Ped/Neo population and the Adult
population. Now let’s break down each point!
Most Accurate
Medications should always be dosed based on the way they are designed to
be dosed- which is weight! It is important to note that some medications are dosed based on
Ideal Body Weight (IBW) and some are dosed based on Actual Body Weight (ABW). It is
important to know the difference. Meds dosed based on IBW will have a theoretical Max Dose
(i.e. 99% of the population isn’t over 7’, so having a max dose that may cut off the 7’6”
Basketball player is a pretty minimal risk), whereas meds that are dosed based on ABW will
have no realistic Max Dose. We have all seen “My 600lb Life”. Giving our patients the correct
dose of the medication ensures the safety of the pt and the effectiveness of the medication
given. We are caring for the patient in front of us, not the hypothetical patient that Fixed-Dose
Guidelines assume is running around everywhere. This seems like a no-brainer.
Math Skills
Let’s all be honest for a moment- we suck at estimating ABW. We suck even more
at med math. For systems that run off of a Fixed-Dose premise (i.e. 2mg for this, 5mg for this,
100mg for this, etc..), there is little math in day to day patient care. This inevitably leads to the
reduction in skill at performing needed calculations under pressure. Additionally, the chances of
a med error will be significantly increased when different concentrations of a particular
medication are introduced to the system (due to shortage, cost, availability, etc.). This also
leads to another HUGE problem for a lot of clinicians- Rounding! This is a slight tangent, but
something that really grinds my gears. I cannot count how many times I have been proctoring a
scenario and the clinician comes up with a number (say 160mg of Ketamine for the RSI of an
80kg pt), and immediately rounds that up to an easier number to remember (like 200mg). That
is a dosing difference of 20%!! We should give the right dose of the right drug to the right patient
via the right route at the right time- every time. It is a simple concept!
Narrowing the Gap
Now, for the culmination of why I believe this is so important! One of the
areas that most clinicians struggle with is Pediatric medication dosing. This is a perceptual
problem that results from the way most clinicians are taught to treat kids. Kids are not small
adults, adults are large kids! The dosing for almost every drug that covers both peds and adults
is the exact same--at the weight-based dose. If we lay a stronger foundation when introducing
concepts to student paramedics, then we could help to reduce the med errors, stress, and
confusion that often result during pediatric calls for service.
The Solution- We begin by teaching a single Weight-Based Dose for every applicable
medication in the drug box. This dose will hold true for all ages of patients! This allows for
comfort and repetition with med math and the dosing of medications for all patient populations. I
also strongly believe that it will reduce the frequency of med errors, as med math will become a
much more frequently used skill. Frequency and practice increase the competency of a clinician
with a specified skill.
Barriers
I believe that the two biggest barriers to this becoming commonplace are the “The
Safety Net” concept, and the general Laziness/Unwillingness to change of some clinicians. I
don’t believe that the latter really needs to be expounded upon, so I will explain the concept of
the Safety Net. Many Clinical Managers and Medical Director’s worry about med errors, and
having a Safety Net for providers on difficult/task saturating calls is their solution for preventing
errors. I recognize this idea and believe that it is a very valid concern. I believe that the idea
behind most Fixed-Dose drug dosages is to help cognitively offload the provider, and minimize
the odds of that provider freezing-up or making an error on the scene.
This is undoubtedly a good thing to have, and helps to protect both the provider and the patient. Common Safety Net
systems such as Handtevy and Broselow are a great fallback to prevent the provider from
making a substantial error. However, these should never be the “go-to” for the clinician.
It is important to have adequate safety nets in place to help prevent medication errors, clinician
stress, and organizational liability. However, these Safety Nets should never become the
primary method of providing patient care. We should always make every effort to give the exact
dose for the exact patient in front of us, not for some hypothetical 100kg person.
alright now go check out the podcast!
