MD order needed to double concentrate gtts?

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    Does your facility require a physician order to double concentrate an IV drip?
    In my facility, we mix some of our own drips, e.g. 40 mg Neo in 1000 ml NSS (or 20 mg in 500 ml).
    We have no hard and fast policy on mixing drips or double concentrating them (or even quadruple concentrating them if we are really trying to limit fluid intake).

    I did not think we needed an order to double concentrate a drip. Another nurse told me that we had to get an order before we did so. When I asked her why, she said "just because that's the way we've always done it." When I said, ok, putting that aside, why do I need an order to double concentrate a drip, she replied, "You are altering the dose of medication." I disagree. I feel like it's 6 of one and half a dozen of the other..I feel as though I can compare it to this, even though the situations aren't exactly the same...if a 1 L bolus is ordered and I use 2 500 ml bags versus 1 1L bag, what is the difference? If 0.5 mg Ativan is ordered and I split a 1 mg tab in half rather than use a 0.5 mg tablet, what is the difference? Thoughts?
  2. 6 Comments so far...

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    No order required where I work. Pharmacy makes most of our drip meds and anytime a drip is 2X, 4X or 8X, a sticker with "Note concentration!" is placed on the bag. The decision to concentrate a drip is dependent on the particulars of each patient; if a patient is on 15 drips and getting 500 ml/hr of drip meds, then it doesn't take a genius to realize that concentrating the drips would be a good idea. OP, your co-worker seems to be confusing concentration and dose; double concentrating obviously doubles the amount of drug per ml but the dose depends on how the pump is set.
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    We have standard drug concentrations that is set per the P&T committee. To alter those concentrations requires and order from a provider faxed to pharmacy. We don't mix any of our drips. Those drips that are not of standard concentration have neon pink "WARNING" stickers to alert us that the concentration is different than the standard.
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    we don't need an order to change the concentration. i think you're exactly right, your co-worker has confused concentration and dosage.

    sometimes I ask the pharmacist to double the concentration because we are going through bags too quickly or the patient is receiving too much fluid.

    an example that comes to mind was an insulin gtt, I was running it at 200+ units/hr (yes...and with the nomogram I was using the hourly CBGs stayed around 900 for close to 24 hours). standard insulin concentration was 100u/100cc and I'm not getting a new bag q30m. I believe I got a 4u/cc bag and still had to call for a new one about 4-5 times each shift.
  6. 0
    Quote from meandragonbrett
    We have standard drug concentrations that is set per the P&T committee. To alter those concentrations requires and order from a provider faxed to pharmacy. We don't mix any of our drips. Those drips that are not of standard concentration have neon pink "WARNING" stickers to alert us that the concentration is different than the standard.
    Are you maybe talking about something crazy like 64 of Levo in a 250 mL bag or 40 of KCl in a 100 mL bag? We can mix our own meds as long as P&T has allowed that concentration to be dealt out by the pharmacy. So if someone codes and we need another bag of Levo real quick we can mix 32 into a 250 as it's a concentration pharmacy allows. If I have someone on a Versed drip and the patient requires high doses, I can ask the pharmacist to mix up a higher concentration bag without an MD order, we just can't ask for insane things like mentioned above.
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    Our policy states that the MD has to order the double concentration. I think one of the reasons is because by doubling the concentration you are changing the original order. Our hospital uses computer orders and the MD has to enter the drug and concentration and what fluid to put it in. If I take it upon myself to double the concentration then technically I have changed the original order and that could bite me in the ass later if something were to happen. However for me it is easy to get it changed because we have a resident on the unit 24/7 so I just have to tell him/her to increase the concentration.

    Like someone else stated, I think your coworker is confusing concentration and dose. The dose of the medication will be the same (20mcgs is 20mcgs), just a different rate depending on the concentration. I think your best best is to look up your hospital policy to see what the "rules" are so that you can cover yourself accordingly.
  8. 0
    Quote from detroitdano
    Are you maybe talking about something crazy like 64 of Levo in a 250 mL bag or 40 of KCl in a 100 mL bag? We can mix our own meds as long as P&T has allowed that concentration to be dealt out by the pharmacy. So if someone codes and we need another bag of Levo real quick we can mix 32 into a 250 as it's a concentration pharmacy allows. If I have someone on a Versed drip and the patient requires high doses, I can ask the pharmacist to mix up a higher concentration bag without an MD order, we just can't ask for insane things like mentioned above.
    No, dude! We have to write orders to change concentrations. Our Levo standard is 8mg/250ml and to change it to anything else we have to write the order. Same for epi, neo, fent, versed, insulin, etc. Our pharmacy is very crazy. There have been many nights where I open a crash cart to mix a gtt because I request one 2 hours ago and still have not received it.


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