Ok To Use 1/2 Bag Of Premix?

[fostercatmom, ASN, BSN, RN]

I work for a small rural hospital at night in the ER. We only have pharmacy open during the day. The new pharmacy director has decreed the house supervisors may not go into the pharmacy for anything but absolutely life and death meds.

The other night in the ER, My LPN needed Vanco 500mg. The ICU and us only had 1000 mg premixed bags. I said it was ok to use half the bag, ie set the pump to 125 cc volume limit. The LPN , strenuously disagreed. ICU agreed with me, the MD's, and the house supervisor agreed with me. Yes, the bags are not exactly 250 cc, but it would be close enough and it was more important for the patient to get something rather than nothing for 8 hours.

What do you think? I hate to think I've been worng all these years....

Thanks

[fostercatmom, ASN, BSN, RN]

Is no one answering me, becuase no one knows or isthe question confusing?

[prmenrs, RN]

I think it would be ok, but get a ruling from the pharmacy ASAP. It would be like using the premixed sol'n like a multidose vial.

What was the LPN's reasoning?

[fostercatmom, ASN, BSN, RN]

Very vaque actually, She kept going on about how if it was in a vial, and you mixed, then it would be ok--I think what she was trying to get at was, the discrepancy of total volume in the bag, but she did go on about policy, however we couldn't find anything about it anywhere.

[babynurselsa, RN]

It should state on the bag mg/ml. There should not be a problem with using it. UNLESS your pharmacist or P&P states differently.

[sister--*]

I recall having to do this once from a premix bag. However, I don't recall the medication. I do know that at the time this was the direction of our pharmacist. I really didn't like doing it like this as I've heard stories of run-away pumps. It certainly required increased vigilance in monitoring.

In my instance I wonder why the pharmacist just didn't remove the excess amount before sending it to the floor....hmmmmm Could it have had something to do with accountablilty if something were amiss?

[fostercatmom, ASN, BSN, RN]

Hi, thanks,it was the middle of the night. Our house supervisor is not allowed in the pharmacy any more. Only under very limited circumstances. I think, you have to trust in the fact that the manufacturer measurses correctly and the little difference in bag fills, won't account for a significant changes in dose. In other words, if the bag says 1 gram in 250cc and you actually have 1 gram in 300 cc.-- and you are only going to give 125 cc(so as to get a 500 mg dose), the difference b/t what you think the pt is getting and what they actually get is minimal.

thanks for your help.

[gertiemae]

I work night shift in a skilled care center. Our pharmacy supplies us with emergency boxes filled with abx, lasix, assorted IV meds, etc.Sometimes the MD orders a dose that is not supplied. Our Vanco does not come premixed, but several other antibiotics do. I would not hesitate to use 1/2 bag of the premixed antibiotics. HOWEVER I would make sure that the bag is well mixed, and draw out 1/2 of the solution, and mark the dosage and amount of fluid plainly on the IV bag. Vanco is not something to fool around with, and I have known IV pumps to be inaccurate. I would feel MUCH safer having removed the extra amount myself. In your case, I would also notify the pharmacy the next morning, so there would not be any question about what the patient had received.

[Jolie, BSN]

Like sister, I would be concerned about the potential for pump programming errors, or accidental free-flow resulting in an overdose.

I would consider giving the med from a premixed 1000cc bag ONLY if I could draw the correct dose (by volume) into a syringe and administer via syringe pump.

[nursebuxom]

with the new pneumonia guidlelines, the patient is to receive the first dose of antibiotic within 4 hours of arrival. There are other such guidelines floating arount out there now too, so it would seem that you are between a rock and a hard place.

I would have removed the excess from the premix bag and given the correct dose, assuming that the volume was not going to be a problem.

[shadowflightnurse]

Unless the facility had a specific policy against it, I would have used the pre-mixed bag. Even if there was a policy against it, I probably would have still done it because it would have been in the patient's best interest. If she was that worried about volume/pump programming errors, she could have withdrawn the un-needed volume before putting it on the pump. if it was 1 gram in 250 ml and only needed 500mg, she could have withdrawn/discarded 125ml and then put it on the pump with the correct VTBI.

[NotReady4PrimeTime, RN]

I'm in agreement that I would go ahead and use the premix... draw out the "extra" volume and discard it, label the bag carefully, document what had been done and move on. Our unit policy states that the first dose of ANY antimicrobial is to be given within one hour of the order being written, a policy that we are continually reminded of with posters and bar graphs of our failure to meet our goal. We too do not have a pharmacist in the building on nights, and a variety of antimics not available on the unit either. We have a night cupboard we can check... SECURITY goes and accesses what we need. I'm not comfortable with that approach, but it's what we do. As a last resort we can call in the on-call pharmacist, but that is heavily frowned upon because it costs big bucks. We've had serious problems with pharmacy not sending up immunosuppressives for our fresh transplants, and I had the nephrologist call in the pharmacist at 0200 one time because then he could take the heat! He was totally fine with that, thank heaven. Patient care should always be priority one!