Medication 20% Rule. - page 2

by kv07 5,824 Views | 18 Comments

Hello ALL. I just recently started on a NICU unit and had just a BRIEF overview on the 20% rule of medication administration. Do all NICU units use this rule???? I am very confused as I am trying to work on some problems... Read More


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    Quote from helicoptergal
    Hi we use the 20% rule in the NICU. We only use it on administration of any narcotic or sedation medication. We draw up 20% of the total amount of the medication and do our medication drug calculations based on this to get the most accurate safe medication doses to give to the pts. For example 100mcg in 1ml the 20% or 0.2ml amt 1st drawn up is 10mcg. If the dose is 2mcg, then we will reconstitute the 0.2ml of Fentanyl with 0.8ml of Sterile water to = 10mcg in 1ml. Then we push out again to 0.2ml which = 2mg of Fentanyl and reconstitute with 0.8ml of Sterile water and then administer to the patient. This process is witnessed by another RN. Hope this helps.
    whats the point?
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    The point is that is our policy, and what our hospital deems as safe administration of narcotics and sedation. Yes time consuming, however it gets fast with addition into your daily practice.
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    Quote from Bortaz, RN
    whats the point?
    The point is that if you give a narcotic such as Fentanyl too rapidly, one of the side effects is chest wall rigidity. The infant cannot ventilate, and will desat. and brady.
    In our unit, we drew up the required dose of narcotic in one syringe.(e.g. 3mcg of Fentanyl=0.03ml of a 100mcg/ml Fentanyl) In a second syringe we drew up 0.3ml of NS. Then we would add the 0.03ml Fentanyl to the 0.3ml NS syringe.
    Let's say your microbore tubing usually has a total volume of 0.3ml. So I would push the med. into the tubing, and set the syringe pump to deliver the total dose over 5-10 minutes. That would include med+flush of an additional 0.3ml of NS, or whatever your unit policy was.
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    Quote from twinkletoes53
    The point is that if you give a narcotic such as Fentanyl too rapidly, one of the side effects is chest wall rigidity. The infant cannot ventilate, and will desat. and brady.
    In our unit, we drew up the required dose of narcotic in one syringe.(e.g. 3mcg of Fentanyl=0.03ml of a 100mcg/ml Fentanyl) In a second syringe we drew up 0.3ml of NS. Then we would add the 0.03ml Fentanyl to the 0.3ml NS syringe.
    Let's say your microbore tubing usually has a total volume of 0.3ml. So I would push the med. into the tubing, and set the syringe pump to deliver the total dose over 5-10 minutes. That would include med+flush of an additional 0.3ml of NS, or whatever your unit policy was.
    We do it slowly, as well, and I fully understand chest wall rigidity. I just don't understand the need to do this:

    Quote from helicoptergal
    Hi we use the 20% rule in the NICU. We only use it on administration of any narcotic or sedation medication. We draw up 20% of the total amount of the medication and do our medication drug calculations based on this to get the most accurate safe medication doses to give to the pts. For example 100mcg in 1ml the 20% or 0.2ml amt 1st drawn up is 10mcg. If the dose is 2mcg, then we will reconstitute the 0.2ml of Fentanyl with 0.8ml of Sterile water to = 10mcg in 1ml. Then we push out again to 0.2ml which = 2mg of Fentanyl and reconstitute with 0.8ml of Sterile water and then administer to the patient. This process is witnessed by another RN. Hope this helps.
    We simply push the small amount of Fentanyl into the microbore, then run the flush (say, 0.5 ml) over 15 minutes to push the med into the baby.

    I don't work in a modern, up to date unit, so don't think I'm just questioning your practice just to question it. I'm genuinely interested in learning better practices than we employ (if this practice IS better...), if it can make us safer caregivers for the babies.
    twinkletoes53 likes this.
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    Quote from helicoptergal
    Hi we use the 20% rule in the NICU. We only use it on administration of any narcotic or sedation medication. We draw up 20% of the total amount of the medication and do our medication drug calculations based on this to get the most accurate safe medication doses to give to the pts. For example 100mcg in 1ml the 20% or 0.2ml amt 1st drawn up is 10mcg. If the dose is 2mcg, then we will reconstitute the 0.2ml of Fentanyl with 0.8ml of Sterile water to = 10mcg in 1ml. Then we push out again to 0.2ml which = 2mg of Fentanyl and reconstitute with 0.8ml of Sterile water and then administer to the patient. This process is witnessed by another RN. Hope this helps.
    This seems unnecessarily error prone. For instance, isn't the end dose in the example above actually 4mcg, not 2?

    0.2ml of 100mcg/ml fentanyl is 20 mcg, not 10. Pushing that out to 0.2ml would be 4 mcg. Adding 0.8ml of water gives you 4mcg/ml. What am I missing?
    Bortaz, RN likes this.
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    That does seem confusing. We actually aren't supposed to dilute fentanyl the way described above. We have to draw up our dose in a 1ml syringe, then we can dilute it a little- but there is no rule as to how much it has to be. Our med tubing holds 0.7ml, so I'll usually dilute to about 0.5. What we can't do is add NS to the ampule to change the concentration of the Fentanyl, and then draw it up.
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    I agree with MunoRN 's math .
    It appears that by adding another layer of calculation , another layer of risk is being added , with no apparent gain .
    Sorry to say but too large a number of nurses appear to be numerically challenged , it is better to find a way to reduce the complexity of a calculation to reduce the risk of miscalculation .
    Gator Girl 2000 and Bortaz, RN like this.
  8. 1
    Quote from helicoptergal
    The point is that is our policy, and what our hospital deems as safe administration of narcotics and sedation. Yes time consuming, however it gets fast with addition into your daily practice.
    This is one of those times where you need to take the steps necessary to send bad policies like these where they belong; in the trash. It's best to avoid 'cutting' medications using multiple steps if at all possible, the safest way is for a single step with a 1/10th dilution (all you are doing is moving the decimal place over 1 place). Luckily, fentanyl is commonly available in a 10mcg/ml strength. Need 2mcg? Take 0.2 mls; just one step and the number itself doesn't change. You can then draw up however much water you want for total volume, the dose is already set.
    Bortaz, RN likes this.
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    Sorry Kv07 the webpage is not letting me respond to your private message, I guess I'm not active enough on the site... So I'll respond to you here!
    So the NP and PA applications are the same it's a dual program. The application process is a bit intense but since it was the first year they were rolling out this new program, I think they were still trying to iron out all the kinks. I've been a nurse for 6 years, and my GPA wasn't that great in undergrad either, but I have quite a lot of international volunteer work on my resume so I think that helped. Good luck on your application!


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