What emergency drugs should be routinely available in the anesthesia workstation for immediate use?

Essential Emergency Drugs for the Anesthesia Workstation

Every anesthesia workstation must be immediately stocked with epinephrine (both IM and IV formulations), atropine, ephedrine, phenylephrine, and medications for anaphylaxis management, as these are the core agents required for life-threatening perioperative emergencies. 1, 2

Cardiovascular Emergency Medications

Vasopressors and Inotropes

• Epinephrine must be available in two concentrations: 1:1000 (1 mg/mL) for intramuscular use and 1:10,000 (0.1 mg/mL) for intravenous administration during cardiac arrest and severe anaphylaxis 1, 2
• Phenylephrine is the first-line vasopressor for treating hypotension, particularly post-neuraxial anesthesia, with typical bolus doses of 50-200 mcg IV 3
• Ephedrine serves as an alternative vasopressor when phenylephrine is unavailable or when bradycardia accompanies hypotension, typically given in 5-10 mg IV boluses 1, 3
• Atropine 0.4-0.6 mg IV treats bradycardia and should be available in pre-filled syringes to prevent medication errors 1, 4
• Metaraminol provides an alternative for refractory hypotension when standard vasopressors prove insufficient 1, 3

Special Considerations

• Pre-filled syringes are strongly preferred for emergency medications that are not used routinely (atropine, ephedrine, phenylephrine) to minimize preparation errors and expedite administration 1

Anaphylaxis Management Kit

First-Line Agents

• Epinephrine 1:1000 (IM): Adult dose 0.3-0.5 mg (0.3-0.5 mL); pediatric dose 0.01 mg/kg, with age-based dosing: >12 years = 500 mcg, 6-12 years = 300 mcg, ≤6 years = 150 mcg 1, 2
• Epinephrine 1:10,000 (IV): For severe refractory anaphylaxis, initial adult dose 50-100 mcg (0.5-1 mL) administered slowly; pediatric dose 1 mcg/kg titrated to response 1, 2

Adjunctive Medications (Second-Line)

• Chlorphenamine (or diphenhydramine): Adult dose 10 mg IV; pediatric dosing: >12 years = 10 mg, 6-12 years = 5 mg, 6 months-6 years = 2.5 mg, <6 months = 250 mcg/kg 1, 2
• Hydrocortisone: Adult dose 200 mg IV; pediatric dosing: >12 years = 200 mg, 6-12 years = 100 mg, 6 months-6 years = 50 mg, <6 months = 25 mg 1, 2
• Ranitidine 50 mg IV (or famotidine 20 mg IV) as H2-antihistamine provides superior symptom control when combined with H1-antihistamines 2

Critical Safety Note

• Corticosteroids and antihistamines provide no acute benefit in anaphylaxis and must never delay epinephrine administration; they serve only to potentially prevent biphasic reactions occurring 4-72 hours later 2, 5

Bronchospasm Management

• Salbutamol (albuterol) nebulized solution 2.5-5 mg in 3 mL saline treats persistent bronchospasm unresponsive to epinephrine 1, 2, 5
• Salbutamol IV infusion provides an alternative route for severe refractory bronchospasm when inhalation therapy is inadequate 1
• Aminophylline or magnesium sulfate IV serve as third-line agents for bronchospasm resistant to epinephrine and beta-agonists 1

Special Circumstance Medications

Beta-Blocker Patients

• Glucagon 1-5 mg IV over 5 minutes (pediatric: 20-30 mcg/kg, maximum 1 mg) followed by infusion at 5-15 mcg/min treats anaphylaxis refractory to epinephrine in patients taking beta-blockers 2, 5
• Glucagon works via non-β-adrenergic pathways to overcome beta-blockade and restore hemodynamic response 2

Fluid Resuscitation

• Normal saline 0.9% or lactated Ringer's solution in 1000 mL bags must be immediately available for rapid high-volume infusion through large-bore IV access during anaphylaxis and severe hypotension 1, 3

Airway Emergency Supplies

• 100% oxygen delivery capability via non-rebreather mask or bag-valve-mask is mandatory 1, 5
• Equipment for emergency cricothyrotomy must be accessible given the risk of rapid laryngeal edema in anaphylaxis 2

Storage and Preparation Standards

Organization Requirements

• Only medications that are absolutely necessary and used regularly should be stored at the anesthesia workstation to minimize selection errors 1
• High-risk medications (particularly neuromuscular blocking agents) require additional labeling on syringe plungers or overlapping the syringe and needle to prevent inadvertent administration 1
• The crash cart composition must be identical across all locations within the institution and formally defined with clearly identified personnel responsible for checking at predefined intervals 1

Labeling Protocol

• Every prepared syringe must be labeled immediately with: drug name (international non-proprietary name), concentration, preparation date/time, preparer's name, and patient identification 1
• Standardized color-coded labels according to pharmacological class reduce reconstitution and administration errors 1

Critical Pitfalls to Avoid

• Never prepare medications in advance except for designated emergency drug sets, which must be labeled with medication, concentration, date, time, and preparer initials, then changed at every shift 1
• Never store multiple concentrations of the same medication on a single anesthesia tray unless absolutely indispensable 1
• Avoid storing potassium chloride at the anesthesia workstation; if unavoidable, implement special precautions for storage, shelving, labeling, and delivery 1
• Read labels aloud twice when performing neuraxial anesthesia to prevent confusion between antiseptics (especially chlorhexidine) and injectable anesthetics, which can cause catastrophic patient harm 1

Monitoring and Documentation

• Mast cell tryptase blood samples (5-10 mL clotted blood) must be obtained at three time points during suspected anaphylaxis: (1) as soon as feasible after resuscitation starts, (2) at 1-2 hours after symptom onset, and (3) at 24 hours or during convalescence to establish baseline 1
• Each tryptase sample must be clearly labeled with collection time and date 1