Diazepam IV - clarification

[Nrscass]

Good day everyone. I have a question that may seem simple but i am spinning my wheels trying to get an answer i am comfortable with. I know what my IV bible says and states about giving Diazepam IV. I happen to like to dilute my drugs if possible. Book says not to dilute because of crystalization/etc. in the line. It is to be given at the port closest to the pt and to give a specific amount over 1 miniute. If this is not diluted it burns really bad going in, no matter how slow it is given, and if it is given closest to the pt it is being diluted no matter what unless the line is pinched off, drip is stopped etc. Let me communicate first that the IV's and line I am talking about are in no longer than 3 hours max. Can an experienced nurse or nurses out there please help me to understand and share your experience with this if you have it?? Yes, I am a new nurse (in my book) and i am looking for input. Thank you so very much in advance.

[NurseMelly11]

IVP Valium should not be diluted. It’s a black box warning actually. When I was a “baby nurse,” I learned this the hard way. 
At any rate, you’re correct that it should be administered through the closest port, if infusing fluids. Be careful, as it is only compatible with certain fluids. 
I usually stop any infusion and give in the IV hub, as this is closest to the patient, and give slowly. Verify blood return prior to administration. This is important because Valium immediately “unconcentrates” in plasma. Kind of neat actually how this works. This is why it is safely administered closest to the patient. I actually like to pull out some blood into the J-loop and then push the Valium. This helps it dilute into the blood and causes less pain for the patient. Valium does tend to burn and can cause phlebitis and infiltration if not done correctly. As stated above, you can safely dilute it in large quantities of compatible fluids, but it depends on how much you are giving and should be verified with pharmacy first. I hope this helps. 

[MunoRN, RN]

5 hours ago, NurseMelly11 said:

IVP Valium should not be diluted. It’s a black box warning actually. When I was a “baby nurse,” I learned this the hard way. 
At any rate, you’re correct that it should be administered through the closest port, if infusing fluids. Be careful, as it is only compatible with certain fluids. 
I usually stop any infusion and give in the IV hub, as this is closest to the patient, and give slowly. Verify blood return prior to administration. This is important because Valium immediately “unconcentrates” in plasma. Kind of neat actually how this works. This is why it is safely administered closest to the patient. I actually like to pull out some blood into the J-loop and then push the Valium. This helps it dilute into the blood and causes less pain for the patient. Valium does tend to burn and can cause phlebitis and infiltration if not done correctly. As stated above, you can safely dilute it in large quantities of compatible fluids, but it depends on how much you are giving and should be verified with pharmacy first. I hope this helps. 

There is no black box warning against diluting IV diazepam, have no idea where you are getting that from.

[NurseMelly11]

10 minutes ago, MunoRN said:

There is no black box warning against diluting IV diazepam, have no idea where you are getting that from.

This came from my med book, multiple physicians I have worked with and learned from over the last 15 years, pharmacists I’ve worked with and our pharmacist actually shared this information with me (see attachments.) The main black box warning is about concombinate usage with opiates, but secondary, as found in medical books and pharmacy resources, is about the incompatibility and warnings if you do not dilute the medication to a certain titration amount (aka: concentration.) You should never dilute Valium unless absolutely necessary, and if so, it’s recommended a 1:40 ration. 5mg per 40 mL of compatible IV fluids. 
Also, there’s no need for being rude in your comments. We are all on here just trying to help and learn from one another. 

[MunoRN, RN]

1 hour ago, NurseMelly11 said:

This came from my med book, multiple physicians I have worked with and learned from over the last 15 years, pharmacists I’ve worked with and our pharmacist actually shared this information with me (see attachments.) The main black box warning is about concombinate usage with opiates, but secondary, as found in medical books and pharmacy resources, is about the incompatibility and warnings if you do not dilute the medication to a certain titration amount (aka: concentration.) You should never dilute Valium unless absolutely necessary, and if so, it’s recommended a 1:40 ration. 5mg per 40 mL of compatible IV fluids. 
Also, there’s no need for being rude in your comments. We are all on here just trying to help and learn from one another. 

Instructions published by third party sources and mandated, ie "black box", warnings are two very different things.  

There are conflicting third party recommendations on diluting I diazepam based on the visible precipitate formed by combing IV diazepam with NS, although sources that have actually studied the result of injecting that diluted mixture into blood have found that the precipitate immediately dissolves when introduced to blood and does not interfere with the pharmacokinetics of the diazepam, so there is no contraindication to mixing it with NS, much less a clear indication it will cause harm to the patient which is what necessitates a black box warning.

[NurseMelly11]

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