Administering opiates

[Emergent]

I was just reading another thread of someone who got accused of diverting because of diluting morphine in a NS bag to administer.

It reminded me of my rules for handling/administering controlled substances.

1) I always unwrap packets in room, whether IV or PO. I want the pt to have NO QUESTION that I'm giving them the right med. I'll leave the wrappers on the counter until next time I make rounds in case they want to sneak a look.

2) I only do a slow IV push for opiate naive pts. For the seasoned user, a faster push gives them the little rush that assures them they are getting the drug they want/need. I do this to instill confidence in the pt that I'm not stealing their med.

3)I always waste immediately unless it's a dire emergency and time is totally of the essence. I'll still bring the empty original container to temporarily leave on the counter.

In short, I'm not here to change the world. If it's ordered, I give it. Controlled substances are treated by me as radioactive materials that can cause me damage.

[xoemmylouox, ASN, RN]

Why do so many of you mix it with NS ahead of time? I push a flush behind it to make sure it all goes in, but why would you dilute it ahead of time? We only do that on medications that can be a vesicant. I want to hear the rationale from somebody first. I think I know what people are thinking, but I need to know for sure. I think that rationale is wrong.

To me, unless specifically instructed to mix a med in NS, it is a med error and should not be done. All of our orders specifically state when to mix a med with NS. And how much. And the most we ever mix with is 3mL, not 10mL. That is for vesicants. I will have instructions for reconstructions to mix 10mL.

I think i understand the thought process, but, it's misguided for several reasons.

You can't make somebody a drug addict by administering some fentanyl or hydromorphone for a few days. That's not how it works. You are not contributing to the drug problem by giving meds IVP. We in the medical community especially should grasp addiction better.

I do not believe diluting it is considered a "med error" as many of these medications are suggested to be diluted (as another posted pointed out as well). I have always been trained to dilute in 10ml NS as this allows you better control of actual dosing and alllows you to follow time guidelines. There is also that "high" feeling which if you have a patient who needs to be up moving around soon or even if they are staying in bed, become a greater fall risk due to the dizziness/light headedness that can accompany slamming an IVP. I suppose it is all in how you were trained. I prefer the "control" that a small dilution can provide.

I have never heard of using a minibag. I think using a NS flush would be a faster/more convenient solution for the nurse.

[Julius Seizure]

Really, it's a nursing judgment call. What happened to allowing us to use our professional nursing judgment?

Right or wrong, I think a part of what happened was instances of some nurses having poor judgement, unfortunately.

(Not meant towards anyone in this thread or even about narcotic administration specifically, just in general.)

[Here.I.Stand, BSN, RN]

• IV Push: Diluent: Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection.Concentration: 0.5–5 mg/mL.
  

So no need to dilute a 2 mg/ml prefilled syringe, correct? My unit stocks the prefilled syringes meant to screw into an injector, and we stock CADD cartridges. If someone is on a Versed drip pharmacy mixes it in a bag, but we have a locked clear plastic box that goes around the pump. It has a window so that we can reach the buttons on the pump, but the drug itself is secured. A minibag hung as a secondary isn't secured.

Plus with the frequency we give IVP narcotics (SICU), that 50 ml each dose can add up to a looooooot of unprescribed extra fluid.

[Horseshoe, BSN, RN]

So no need to dilute a 2 mg/ml prefilled syringe, correct? My unit stocks the prefilled syringes meant to screw into an injector, and we stock CADD cartridges. If someone is on a Versed drip pharmacy mixes it in a bag, but we have a locked clear plastic box that goes around the pump. It has a window so that we can reach the buttons on the pump, but the drug itself is secured. A minibag hung as a secondary isn't secured.

Plus with the frequency we give IVP narcotics (SICU), that 50 ml each dose can add up to a looooooot of unprescribed extra fluid.

My unit used the pre-filled syringes as well. They were already diluted, so no need to do anything further.

In my current facility, we use fentanyl, and they are not in pre-filled syringes; one must draw it directly from the bottle.

[Here.I.Stand, BSN, RN]

My unit used the pre-filled syringes as well. They were already diluted, so no need to do anything further.

In my current facility, we use fentanyl, and they are not in pre-filled syringes; one must draw it directly from the bottle.

I see. Our Fentanyl comes 100 mcg/2 ml...but now that you mention it at my old facility the fentanyl did come in vials. I'd forgotten about that. I do see how for tiny volumes, diluting it a bit can help with accuracy. It seems like a fair percentage of =0.5 ml could be stuck in the syringe once the plunger is completely depressed.

[cjcsoon2bnp, MSN, RN, NP]

This is a very interesting conversation, to say the least.

In my practice, I tend to draw up narcotics or sedating medications with additional 0.9% NS because I find that it's easier to control the rate of administration so that I can actually achieve the time recommended by the manufactuer. Most of the time I typically prepare the medications right in front of the patient so they know that I am giving them exactly what they are ordered to receive. I don't push opiates or other CNS depressants faster than recommended because of the potential side effects: rapid decrease in HR/BP, worsening nausea or vomiting, lightheadedness, or chest rigidity (in the case of Fentanyl).

Because I work in the ED and so if I think a patient is opiate-nieve and would benefit from having their medication administered in a 50 mL bag 0.9% NS (frail elderly, young child etc.) I will talk with the MD/NP/PA and typically it's not a problem but I can see where it might an issue in other settings (especially if the patient has CHF and is on a fluid restriction).

!Chris

[Esme12, ASN, BSN, RN]

That is amazing to me.

Some facilities to control narcotics, or there are LPN's that can't administer IVP meds, routinely will make up small bags.

[Horseshoe, BSN, RN]

Some facilities to control narcotics, or there are LPN's that can't administer IVP meds, routinely will make up small bags.

Okay, that makes sense.

[mmc51264, BSN, MSN, RN]

They only time I might push and IV straight is if the docs are in the room and going to do something painful (they never give enough advance warning to properly pre-medicate). I usually ask for a one-time dose if necessary if they are dong a painful dsg change or a wound vac exchange. It is truly about pain management for the patient. They appreciate it too.

[nutella, MSN, RN]

Narcotics.....

it depends really on the hospital with their P&P, on the patient and opiate naive or not, the situation, and what the goal is.

When there are concerns about patients asking for iv narcs due to the "high" it is often ordered as an infusion over 20 minutes or such.

The cartridges can be used with the injector undiluted, which is common post surgery or in acute pain situations.

In my experience, the nurses who get accused of diversion usually have some kind of pattern when it comes to administering, wasting, or signing out in the electronic system. Often, there are also other concerns. I do not think that pushing narcotics fast to elicit a "high" in a patient is a valid method of instilling trust and assurance of non diversion. Leaving empty cartridges or vials around is also strange.

The best method is to follow P&P, assess the patient, take out the medication, waste if needed right away with the witness, administer the medication and discard the syringes. Document the pain after administration. Don't carry around medication "just in case" , hang on to vials, wait to waste and so on.

[Kssrn404]

In the ICU setting, many times it is IVP for narcs. Diluting would take too long.

ABSOLUTELY!!! When you're assisting a trach or PEG insertion at the bedside there's no time to "dilute" Versed or Narcuron or morphine. I may dilute in a 10 ml syringe depending on how much the physician gives with each dose. IVP is all we do with the exception of PCA's.

[Kssrn404]

I have never seen opiates diluted in a mini bag, ours are given IVP either diluted in a syringe or diluted with the running fluids if compatible.

I just had a very good friend of mine fired from a job and is being investigated for diversion. This RN followed the protocol shown during preceptorship and although apparently other RNs followed the same protocol it was incorrect and now the hammer is dropping. I feel horrible for my friend. Stories on here about diversion accusations and Pyxis screw ups make me nervous, i'll admit. I personally think it would be a great idea to have a camera in the med rooms to cover some of these incidences. I follow waste protocols to the letter, but I still feel like they can ruin you somehow (yeah the stories have made me a smidge paranoid!)

Wanted to add, our push opiates have to be drawn up in the med room per protocol. If there's a waste we have to draw up the entire available amount and squirt out our waste in front of the witnessing RN before even going into the patient's room. We would have our butts handed to us if we drew up these meds in the patients' rooms so there's no way we can draw up in the presence of the patient.

We too have a camera in our Med room. We also are required to draw up the marcotic in the Med room before going to the bedside. We have a finger print system.

When doing a bedside procedure and sedation is required you sometimes have to draw up the entire vial say of versed in case the MD wants to use most of the vial. We then go back to the Med room and waste/witness in the pixis.