Diluting Ativan?

[Guest838984]

OK, my ER peeps. So my new boyfriend is an ICU nurse, and we somehow came on the subject of Ativan, and he told me that it HAS to be diluted. I was like, "What?? I've never done that, or been told to do that, or seen any other nurse do that". But when I look it up, it says to dilute it. I've been working for six years and feel like a complete idiot for not knowing this before. I want all your input on this. Just out of curiosity, really. 

[MaxAttack, BSN, RN]

They also say to administer it over a few minutes, but when has that happened? 

I dilute it now and then, depending on my mood. I never could find the reason, but I would love to hear if someone knows why.

[kaylee.]

It's thick like syrup; that is why I dilute it.

[MunoRN, RN]

Your new boyfriend is incorrect.

Every couple of years, the Institute for Safe Medication Practices (ISMP) puts out a reminder that it's a common myth that IV push medications must be diluted and that doing so might do more harm than good.

ISMP recommends only diluting when the manufacturer's FDA labeling recommends doing so, and when evidence exists to support doing so, for lorazepam, it's not recommended or even suggested. ISMP points out that the myth is common enough to be included in various drug guides, but these commercial products are not peer-reviewed or evidence-based.

Sometimes it's necessary, for instance, if you need to draw up 0.5mg of lorazepam from a 2mg/ml vial and you only have 5 ml syringes. Still, generally, it's not beneficial and should be avoided.

https://www.ismp.org/resources/some-IV-medications-are-diluted-unnecessarily-patient-care-areas-creating-undue-risk

https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP97-Guidelines-071415-3. FINAL.pdf

https://www.ismp.org/resources/part-I-survey-results-show-unsafe-practices-persist-IV-push-medications

 

[MaxAttack, BSN, RN]

MunoRN said:

ISMP recommends only diluting when the manufacturer's FDA labeling recommends doing so, and when evidence exists to support doing so

The FDA information provided by Baxter:

"Immediately before intravenous use, ATIVAN Injection must be diluted with an equal volume of compatible solution."

https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/018140s028lbl.pdf&ved=2ahUKEwjWtJ7EyIPtAhVthOAKHUmuAZoQFjALegQIFxAB&usg=AOvVaw0cQOQgFgBdceXBx6GMCdug

[JKL33]

Nicole5128 said:

 I was like, "What?? I've never done that, or been told to do that, or seen any other nurse do that". 

Well, that's just weird. It sounds like too many nurses heard that things don't need to be diluted in many situations, so they just went with that mantra instead of looking it up. It's right in the labeling info, and here's the active link.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/018140s028lbl.pdf

 

[turtlesRcool]

I've always diluted it.  I don't know how IVP lorazepam is packaged in your hospital, but we draw ours up from single-use vials with a label instructing dilution.  When you dilute it, you can see it swirling in the syringe - lorazepam is thick.

I am a compulsive label reader, even in the supermarket.  I check and recheck the dilution requirements for everything I draw up, especially since we switched to IVP for many antibiotics.  Even if it's something I've given before, at minimum, I look at the label to make sure nothing changes.

I advise checking for the official policy or manufacturer's instructions rather than following other nurses' instructions.

[JKL33]

There's an old (1998) FDA approval for lorazepam labeling available online, it's tough to read, but it instructs on the need to dilute even the pre-filled syringes. The described procedure was to extrude the extra air from the pre-filled syringe and then withdraw the appropriate amount of diluent into the syringe. Probably neither here nor there; I've never seen any manufacturer or FDA information suggesting that Ativan or the generic lorazepam was not to be diluted. I would be interested to know where anyone got the idea it wasn't intended to be cut.

[caliotter3]

turtlesRcool said:

I've always diluted it.  I don't know how IVP lorazepam is packaged in your hospital, but we draw ours up from single-use vials with a label instructing dilution.  When you dilute it, you can see it swirling in the syringe - lorazepam is thick.

I am a compulsive label reader, even in the supermarket.  I check and recheck the dilution requirements for everything I draw up, especially since we switched to IVP for many antibiotics.  Even if it's something I've given before, at minimum, I look at the label to make sure nothing changes.

I advise checking for the official policy or manufacturer's instructions rather than following other nurses' instructions.

Over the years, I have learned some things from reading labels and printed materials that I have incorporated into my practice. Glad to see others read labels too.

[0.9%NormalSarah, BSN, RN]

Oh, dear, I have not been diluting. I typically rely on my MAR as it provides administration instructions from a pharmacy, and if it doesn't make sense to me, I will look it up. This thread is causing me to change something about my nursing practice; I will be reading those labels more carefully! I wonder why our pharmacy instructions don't include it, though. I wonder if our pharmacy has decided there is no pertinent reason to dilute or if they figure we nurses know what we're supposed to do.

[spotangel, DNP, RN, NP]

I never diluted it but pushed it slow. I was flushed before and after.

Just read the link below, and I was like oops! I need to dilute.

 CNS depression, being overly sedated over 50 yrs of age, angioedema, and resp arrest/cardiac arrest are some reasons for dilution.

Interesting read!

https://www.pfizer.ca/sites/default/files/201909/Lorazepam_PM_E_230606_22Aug2019.pdf

[Guest838984]

0.9%NormalSarah said:

Oh, dear, I have not been diluting. I typically rely on my MAR as it provides administration instructions from a pharmacy, and if it doesn't make sense to me, I will look it up. This thread is causing me to change something about my nursing practice; I will be reading those labels more carefully! I wonder why our pharmacy instructions don't include it, though. I wonder if our pharmacy has decided there is no pertinent reason to dilute or if they figure we nurses know what we're supposed to do.

Same here! Our mar doesn't say anything, I can't say I've looked at the vial, but it comes in a carpet which I always assumed was for direct injection. I asked my ED pharmacist the other day, and she said there's no need to dilute it, and I asked if it would prevent it from being caustic to the veins. She said no, but an FDA label thinks it must be diluted. I told her this, and she still said it didn't have to. I'll take a closer look at the vial next time I pull it, and I am also changing my nursing practice and always learning something new in this profession. I agree some meds are unnecessarily diluted, but I think it's usually not harmful.