Best Practice #9 FAQ
Best Practice #9: Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Have standardized protocols and/or coupled order sets in place that permit the emergency administration of all appropriate antidotes, reversal agents, and rescue agents used in the facility. Have directions for use/administration readily available in all clinical areas where the antidotes, reversal agents, and rescue agents are used.
1. Question: I noticed that as an example of an antidote in Best Practice 9, flumazenil is recommended to counteract the effects of benzodiazepines. There is evidence in the literature that recommends against the use of flumazenil for the treatment of benzodiazepine overdose (Am J Health-Syst Pharm. 2012; 69:199-212). Why do you recommend it?
Answer: Flumazenil in this case is used only as an example, and it is the responsibility of each individual hospital to decide which antidotes should be made readily available for use. While there may be a limited role for flumazenil in acute overdose, it is still administered in select patients to reverse excessive sedation and respiratory depression as a result of benzodiazepine use during procedural sedation.1-4 The American Society of Anesthesiologists still recommend that antidotes which reverse opioids and benzodiazepines be readily available during moderate and deep sedation.3,4
- American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 10.2: Toxicology in ECC. Circulation. 2005;112(suppl): IV-126–IV-132.
- Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm. 2012;69(3):199–212.
- American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-17.
- Apfelbaum JL, Silverstein JH, Chung FF, et al. Practice guidelines for postanesthetic care: An updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. 2013;118(2):291–307.
2. Question: We are struggling with what type of “emergency administration” we would want to sanction. How are people doing this?
Answer: We are aware of organizations that are including rescue/reversal agent orders (with specific administration directions) into their standard order sets so that healthcare practitioners (e.g., nurses) have appropriate orders available should they be clinically necessary to emergently reverse the effects of certain medications. This prevents a practitioner from having notify the prescriber or wait for a call back when reaction is occurring to obtain an order for the rescue agent. For example,
All medication order sets with opioids would have a standard set of naloxone orders provided in the event of respiratory depression.
All insulin order sets would have a hypoglycemia protocol available with associated medication orders.
All orders for topical benzocaine spray would have a standard set of orders for methylene blue (with mixing directions) administration in case methemoglobinemia would occur.
All order sets for medications that have a high incidence of infusion reactions (e.g., rituximab [RITUXAN]) would have embedded orders for treatment of anaphylactic reactions (i.e., EPINEPHrine, steroids).
This would prevent the practitioner from pulling the medication on override, without an order; looking up appropriate dosing/administration information; or delaying treatment.