I'm currently under fire from my ICU manager because I administered "Ativan 4mg IV Now" as ordered by the physician, to a patient who was delerious, restrained at wrists to bed, and had a transcutaneous pacemaker delivering 80 shocks/minute (the transvenous pacemaker was not working due to not being advanced far enough.) An earlier 1mg dose did nothing for the fellow. The only effect of the 4mg dose was therapeutic----the patient slept for 3.5 hours before again waking up, pulling at restraints and required more sedation.
The manager's position is I should have questioned the size of the dose. It does not matter to her that I gave the 4mg slowly over 6 minutes (three times slower than the Nursing 2003 drug handbook
My position is this was an appropriate and safe order. I'm looking for either supportive literature or even better, an expert witness. I have grieved this through my union. We believe administration is targeting me due to my position on the bargaining team (we are currently negotiating a new contract.) The case is now going to arbitration and we are about to file an Unfair Labor Practice against the hospital.
Aug 4, '03
My plan for the presentation of the caution I used will be:
1. Checked order with senior ICU RN (who agreed to appropriatness)
2. Patient's weight 89 Kg (very muscular/robust 90 year old) (Nursing 2003 Drug Handbook
lists upper dosing levels at 0.05mg/kg up to 4mg may be needed. 89x0.05=4.45mg
3. Administered 3 times slower than literature allows
4. Patient continued to pull at restraints until very end of drug administration (titrated)
5. Patient on 5 wire ecg monitor and continuous SAO2 (described to lay arbitrator as: monitors keeping track of every breath patient takes and second by second blood oxygen level; would alarm if levels of either dropped too much). RN always within visual sight of patient. Patient remained hypertensive and tachypneic throughout night
6. Will discuss risk vs. benefits of administration. (risk of patient working through/around restraints and pulling off pacer wires if not enough sedation administered.) Patients undergoing this level of noxious stimuli for hours are more likely to need the highest doses of anxiolytics.
7. Flumazinil/Romazicon 30 feet from patient in OmniCell drug dispensing machine.
8. Ambu-bag 2 feet behind patient's head at all times.
Thanks for the suggestions. Any other suggestions are welcome.
Last edit by Dierdron on Aug 4, '03