Diluting all IV push medication??

Nurses General Nursing

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I had a nursing instructor tell a nursing student that "you must dilute all IV push medication with at least 10cc NS." I know that there are medication that must be diluted, but not all? I have not been able to find this standard in AL's nursing standards, just wanted to see if anyone knew of this being a nursing standard in your state and if so, where I could find information on the rationale. I think it could be a great implementation at my hospital, but first must find the evidence to back the idea. Thanks

Is diluting pain or cardiac medications even evidenced-based? Or just nurses being too worried? As long as you push at the correct rate and then flush at the same rate of the drug I see no need in diluting. People diluting phenergan to make it less irritating on the veins is not evidenced-based either from what I've read the pH does not change despite adding a few cc's of saline. It's going to irritate the vein regardless. Although it is good practice to administer in an already infusing line to reduce the likelihood of extravasation. Do you really think that extra 2-9 cc's of saline is going to make a world of difference when it's dumped into 5-6L of blood?

Specializes in ICU, Telemetry, PACU, Med-Surg.
Is diluting pain or cardiac medications even evidenced-based? Or just nurses being too worried? As long as you push at the correct rate and then flush at the same rate of the drug I see no need in diluting. People diluting phenergan to make it less irritating on the veins is not evidenced-based either from what I've read the pH does not change despite adding a few cc's of saline. It's going to irritate the vein regardless. Although it is good practice to administer in an already infusing line to reduce the likelihood of extravasation. Do you really think that extra 2-9 cc's of saline is going to make a world of difference when it's dumped into 5-6L of blood?

The Institute for Safe Medication Practices suggests that "...further dilution of the 25 mg/mL strength [promethazine] to reduce vesicant effects and enable slow administration. For example, dilute the drug in 10 to 20 mL of normal saline if it will be administered via a running IV, or prepare the medication in minibags containing normal saline if there is time for pharmacy to dispense them as needed for individual patients. (Trissel confirms that promethazine is physically compatible when diluted in normal saline, with little or no drug loss in 24 hours at 21 degrees C in the dark, when prepared in glass, PVC, and polyethylene-lined laminated containers [Handbook on Injectable Drugs, 13th edition. ASHP, Bethesda, MD; 2005:1266].) Extravasation can also be recognized more quickly when promethazine is diluted than if the drug is given in a smaller volume."

So, yes, I think it is pretty much universally accepted that you SHOULD dilute phenergan. Honestly, would you like to receive it undiluted?

Specializes in ICU, Telemetry, PACU, Med-Surg.

You can find the entire article I quoted here: http://www.ismp.org/newsletters/acutecare/articles/20060810.asp

Phenergan's pH is 4.0. A 10-fold dilution will result in a negligible change in the pH ( ~+ 0.3). NaCl is the salt of a strong acid and strong base and has a neutral pH. Promethazine is considered a weak acid and is only partially dissociated in solution. The degree of dissociation is proportional to its Ka (dissociation constant). Larger Ka --> stronger acid (greater dissociation). The pH of promethazine after a 10-fold dilution (or greater) is still quite low. So it's still going to irritate the veins to a great degree. Of course I always dilute it per hospital policy but as you can see diluting does little to no help in patient comfort as the pH remains the same. I was mainly targeting the individuals who believe all opioid analgesics or cardiac meds should be diluted.

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

Follow your facilities' IV drug book for guidance, otherwise you'd be breaking the law by not giving & reconstituting drugs properly.

U can dilute drugs in a number of different ways. It depends sometimes (where I've worked anyway) on the facilities and the consultants' preference. But I wouldn't be diluting any IV drug with anything less than 10mls, cos patients can get phlebitis due to the tunica intima being irritated. Most younger persons veins probaly wouldn't get irritated, but think of old people & kids & their frail veins.

Specializes in Med/Surg, DSU, Ortho, Onc, Psych.
Phenergan's pH is 4.0. A 10-fold dilution will result in a negligible change in the pH ( ~+ 0.3). NaCl is the salt of a strong acid and strong base and has a neutral pH. Promethazine is considered a weak acid and is only partially dissociated in solution. The degree of dissociation is proportional to its Ka (dissociation constant). Larger Ka --> stronger acid (greater dissociation). The pH of promethazine after a 10-fold dilution (or greater) is still quite low. So it's still going to irritate the veins to a great degree. Of course I always dilute it per hospital policy but as you can see diluting does little to no help in patient comfort as the pH remains the same. I was mainly targeting the individuals who believe all opioid analgesics or cardiac meds should be diluted.

Wish I'd known u when studying for my chemistry exam! I've unfortunately forgotten a lot of it now.

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