Response

Thank you for your response to our article, “Pharmacotherapy Considerations for Inpatient Advanced Cardiac Life Support.”1 We appreciate your engagement and the opportunity to clarify some of the context surrounding the referenced section regarding dilution of epinephrine in emergent clinical scenarios.We fully support and agree with the Institute for Safe Medication Practices (ISMP) recommendations, which identify the use of commercially available prefilled 0.9% sodium chloride flush syringes as a diluent as an unsafe and off-label practice. We recognize the concerns regarding device classification, syringe markings, and the risk for dosing errors and mislabeling. These are pertinent safety considerations, and we appreciate the efforts to reinforce best practices that many organizations have worked hard to standardize.The intent of our article was not to endorse routine use of flush syringes for medication preparation, nor to suggest this approach aligns with ISMP or manufacturer guidance. Rather, this statement was included to recognize that in some real-world, time-critical advanced cardiac life support (ACLS) scenarios, particularly in areas with limited clinical resources and immediate medication availability, clinicians may be forced to use supplies available at the bedside. In these circumstances, rapid access to the appropriate concentration of epinephrine can be imperative, and clinicians occasionally must adapt while maintaining situational awareness and mitigating risk as much as possible. This portion of our article was to serve as education on how to prepare an ACLS dose of epinephrine with limited resources; however, we acknowledge that the suggested dilution methods may result in some variance in the total volume of normal saline diluent. We are of the belief that a 0.5 to 1.0 mL difference in diluent is likely to be of minimal clinical impact in an emergent situation and would generally be considered a preferred alternative to potential delays in medication administration if other resources are unavailable nearby.We agree that the preferred and safest practice is to prepare intravenous push medications using standard medication syringes with appropriate diluents, labeling, and verification processes. When prefilled, ready-to-administer epinephrine products or medication-rated diluent vials are available, they should be used. Our intention was to reflect the operational challenges that some patient care units encounter during cardiac arrest events—not to imply that this represents the recommended or ideal method.We appreciate your thoughtful feedback and your shared commitment to advancing safe, standardized, evidence-based medication practices in acute and critical care. We remain aligned in the goal of supporting both medication safety and the realities of emergency clinical practice.