IV Fentanyl use on Med/Surg Unit - page 3

I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are... Read More

  1. by   nilepoc
    Quote from PA-C in Texas
    I think it is about being conscientious about your medication. You certainly wouldn't want to throw this stuff in like its some adenosine. I spoke with a floor nurse friend of mine who stated that she will either push it in increments over 2-5 minutes, or set it in a 100 cc bag and run it in at 20 cc/min.

    I have seen MS and a variety of other things cause almost instantaneous respiratory collapse too, but that doesn't mean we refuse to use it now. You simply have to take precautions. That is a risk of the medication that the prescribing clinician has decided is outweighed by the potential benefits. I administer all of my schedule II narcotics personally and always keep a dose of naloxone in my shirt pocket when doing so. I mean, the stuff is cheap, it doesn't have to be refrigerated, and when those unexpected things do occur, they can easily be reversed.
    Except in the case of fentanyl induced chest wall rigidity which can only be reversed through the use of muscle relaxation (paralysis). Note this also requires the placement of an endotracheal tube in most cases. Which it sounds like you can do (PA-C), but there are others who lack that training.
  2. by   nilepoc
    Quote from ocankhe
    If Fentanyl is used in PCA or in an epidural infusion on your med surg floor what is the concern if it is ordered IVP. Whats the difference between a PCA IV bolus and an IVP?
    To me all the pump is doing is pushing the Fentanyl into a running IV instead of the RN pushing it. Same drug, same doses same potential for side effects?
    That said if your argument for not using FentanylIVP is because of its short duration and should be utilized via PCA to assure better pain control that can be a valid arguement. Or if the usual patient load would preclude close monitoring that is another arguement. However, if you are arguing that the patient load is too great to allow for adequate assessment of IVP Fentanyl then I would say it is also to0 high to care for patients with PCA or continuous epidural infusions.
    Epidural delivery of Fentanyl is associated with less respiratory depresant effects than IV delivery. Also less respiratory effects than morphine given epidurally.
  3. by   kyti
    I work in pacu, fentanyl is our main drug of choice, but I do not think it should be used IVP on a med/surg unit. For one it is too short acting. Why not chose diluadid or something else. Secondly it can cause chest wall ridgidity as mentioned before. Third the dose is very individual. I usually give 25-100 mcgs at a time q5min. prn up to a total dose of 250-500 mcg. Some people can tolerate 100mcg at a time 500mcg total and never bat an eye and still c/o pain. Other people you give 25mcg to X1 and they are apnic and you are stimulating them to breathe or giving narcan. Should only be used if you can monitor 1:1 with pulse ox. for at least 20 min or longer. I love it in the PACU but why chose it for med/surg when you have many other options.
  4. by   OC_An Khe
    Nilepoc
    Your point about epidural fentanyl is well taken. I included epidural infusions as no matter what drug is used epidurally it requires more frequent assessments then the traditional PO/IM analgics thus patient load is more a factor in whether nurses are comfortable caring for these patients.
    Last edit by OC_An Khe on Apr 6, '04
  5. by   pickledpepperRN
    The California Board of Registered Nursing is clear that CONTINUOUS MONITORING IS REQUIRED.
    The RN must not leave the patient and must not have other duties, such as assisting the physician. The patient must be a 1:1 until recovered from the medication. Fentanyl is such a medication. Conscious sedation may become deep sedation or anesthesia so our board protects the best interest of the patient.

    http://www.rn.ca.gov/policies/pdf/npr-b-06.pdf
  6. by   ?burntout
    Quote from rn-pa
    i have never seen it ordered on our med-surg unit. we only see fentanyl in continuous epidurals (with continuous pulse ox and frequent vs) or in a patch.
    ditto. we have never had an order for fentanyl iv push. the only time we ever see fentanyl is in an epidural for pain management and we rarely get epidurals anymore: they are usually on a pulse ox and telemetry with vs q 4 hours-at least.
  7. by   skyblue5454
    Quote from abdnnurse
    I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

    We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?
    We give fentanyl via epidural and pca which require q1hr monitoring of pulse ox and pain scale as well as respirations. It is a high level of care. We do not give fentanyl iv push nor do I know anyone who does push it on the floor in the general patient population.I hope you and your peers do extensive research and check with state board of nursing. It is my understanding that the determination for use of fentanyl as analgesia vs analgesia is made by the concentration of the medication. Good look. I will be following your thread to see how others respond.
  8. by   mattsmom81
    Hmm. Perhaps my facility is not as cautious with this as they should be. Of course given the incident I described on the floor several weeks back perhaps it IS best kept to critical care areas when given IV . I have seen a lot of Fentanyl IM ordered as a preop med which shouldn't be a problem on the floors. I guess I have looked at it the same way I have looked at Demerol and MS..and have always been very cautious with IV doses of ANY of these.
  9. by   kids
    Quote from spacenurse
    The California Board of Registered Nursing is clear that CONTINUOUS MONITORING IS REQUIRED.
    The RN must not leave the patient and must not have other duties, such as assisting the physician. The patient must be a 1:1 until recovered from the medication. Fentanyl is such a medication. Conscious sedation may become deep sedation or anesthesia so our board protects the best interest of the patient.

    http://www.rn.ca.gov/policies/pdf/npr-b-06.pdf
    The link addresses conscious sedation, not Fentanyl used for pain management.
  10. by   Critical care rn
    I would not be in favor of this. Doesn't JCAHO say that physicians can not write ranges? If they can, then I think your hosp needs a policy about starting at the lowest dose, providing adequate monitoring such as spO2 and vital signs. Until you are sure of being covered in aspects such as this, and given adequate inservice education to show competencies, I would not give this medication.:uhoh21:
    Quote from abdnnurse
    I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

    We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?
  11. by   abdnnurse
    Thank you for all the information you all gave. It is now in the hands of management and I can only hope they will do the right thing. Our nursing management does have major concerns so I believe we and our patients will be protected. I will keep you all posted.
  12. by   nursebonkers
    All I have to say is theres always narcan!~!!!! I have given fentanyl and have had blue patients, I have given dilaudid and have had blue patients, FUN=FUN-FUNFUN!!!
    and then again not so fun!!
    At my institution fentanyl can not be given on a medsurg, tele, or pcu unit, As long as its in the policy of the hospital or institution you work at, and its ok to give per hospital policy without a 1-1 monitor, then give it, if the patient dies your covered. I love to quote hospital policy when someone tells me to do something that I know isnt allowed the patient care manual. Really? an RN was fired, I guess there isnt a nursing shortage in your neck of the woods. I can be as stubborn as I want and no ones firing me. No one wants my job.
  13. by   abdnnurse
    The idea about giving it as long as it is hospital policy probably wouldn't fly in a court of law. I think it goes something like this..."what would any PRUDENT
    nurse do in a similar situation".

    One thing I know for certain is that fentanyl is NOT just another narcotic. It causes problems that narcan can't fix...I'll stick to my Morphine thank you very much.

    This little debate has made me more certain than ever that I personally won't give it on a med/surg unit. I'd rather be fired and have my license in my pocket than lose it because I didn't use the knowledge I have. Another thing....if the patient died it won't matter if there was a hospital policy or not....I would know that I did not do everything I could to assure the patient's safety. If I get fired I can sue the hospital or just find another job...if the patient dies, that was a human being who trusted me to deliver the safest care possible! We are patient advocates, that is an important nursing responsibility.

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