mixing pain medications with a flush

Nurses General Nursing

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i was always taught this... mixing my morphine OR dilaudid in a 10 cc flush and push into patient.

a patient asked me, why is that necessary? i couldn't explain.

also, i've gotten orders before to dilute (mix with flush) and to DO NOT dilute (draw and give) form the pharmacy. if i dilute OR NOT dilute the medication, is this a medication error on my part?

There were originally some practical rationales r/t dilution of medications for IV push; it's not as if all of them were crazycakes even if this is no longer en vogue or really necessary.

Simple example - morphine didn't used to come from manufacturer as a nice little 2 mg/ml prefilled syringe; it was 10mg/1 ml vial or even an ampule. If your order was to give 2 mg, obviously that would be 0.2 ml. At the time it didn't make sense to push 0.2 ml into a saline lock over (supposedly) 2 minutes and then push the flush quickly (as flushes are typically pushed). To do so would've meant giving the patient 0 mg over 2 minutes, and then 2 mg over 1 second. And there used to be a lot more patients sitting around in hospitals with heparin/saline locks.

There's no need to talk about things as if they are [implied: always were] nonsense simply by virtue of the fact that things have changed. And a lot of confusion and conflicting instruction could be cleared up with just a smidge of historical information and an effort to put things into context.

I appreciate the work of the ISMP, but to read their commentary on this you'd think that not one nurse in the past ever diluted a medication in a syringe, labeled it, carried it to a bedside, and administered it appropriately. They also don't offer much commentary on some of the various IRL issues like the fact that ketorolac burns and morphine has been known to cause a red streak or two unless it's pushed through a bolusing IV or else........diluted. I've had quite a few people tell me they're allergic to morphine and when I ask what the reaction was: red streak.

Bah. I guess count me as one who isn't too alarmed either way.

There were originally some practical rationales r/t dilution of medications for IV push; it's not as if all of them were crazycakes even if this is no longer en vogue or really necessary.

Simple example - morphine didn't used to come from manufacturer as a nice little 2 mg/ml prefilled syringe; it was 10mg/1 ml vial or even an ampule. If your order was to give 2 mg, obviously that would be 0.2 ml. At the time it didn't make sense to push 0.2 ml into a saline lock over (supposedly) 2 minutes and then push the flush quickly (as flushes are typically pushed). To do so would've meant giving the patient 0 mg over 2 minutes, and then 2 mg over 1 second. And there used to be a lot more patients sitting around in hospitals with heparin/saline locks.

There's no need to talk about things as if they are [implied: always were] nonsense simply by virtue of the fact that things have changed. And a lot of confusion and conflicting instruction could be cleared up with just a smidge of historical information and an effort to put things into context.

I appreciate the work of the ISMP, but to read their commentary on this you'd think that not one nurse in the past ever diluted a medication in a syringe, labeled it, carried it to a bedside, and administered it appropriately. They also don't offer much commentary on some of the various IRL issues like the fact that ketorolac burns and morphine has been known to cause a red streak or two unless it's pushed through a bolusing IV or else........diluted. I've had quite a few people tell me they're allergic to morphine and when I ask what the reaction was: red streak.

Bah. I guess count me as one who isn't too alarmed either way.

Boy-o-boy you nailed it! I couldn't remember why I sometimes diluted....I just assumed I must have been "crazycakes".

Specializes in Critical care, Trauma.

When I worked a post-surgical unit I would dilute all of my narcotics. We gave so many, and often times people would be nauseated, flushed or light-headed in response to the various meds. A few people I found I could avoid any nausea with them if it was given suppppper slow. I also tended to find that Fentanyl would cause a quick dip in Spo2 if not given extra slow as well. I don't do this much anymore but in the ICU a lot of our narcs are in infusions rather than IV push.

Notices were sent out about how we should not be diluting because it's considered "compounding"...which I never really understood because it's the same process that we do for Protonix (reconstituting powder), Pepcid (diluting a liquid IV med), etc. My only concern was that if you set down your flush that had the med in it, it could be a cause for confusion later. I've heard about cases where a med in a flush was given because a different nurse saw the flush, assumed it was like any other regular/non medicated flush, and gave it to a patient with ill effects. So my personal policy is that I never use a flush that I didn't personally open.

I worked on a unit that would detox and would also see a lot of (ahem), return patients with chronic pain issues. We decided as a unit to dilute pain meds because some of these patients LOVED the rush you get from pushing narcotics (they would often say "push it fast please"). We decided collectively that we would dilute do that these patients knew they were not going to get that experience on our unit.

As someone who has been in the bed due to orthopedic surgeries, pushing narcotics even slowly can make some patients (including me) have systemic reactions, such has head rushes with lingering headaches, nausea, vertigo, tachycardia, and many others. As other posters have said pushing .5mL of Dilaudid slowly is very difficult. When I worked on the adult unit listed above, I never had a patient complain about the morphine headache side effect, I wonder if it was because we always diluted.

I have diluted before when the medication being administered caused the patient to complain previously that it "burned."

I believe that MunroRN was spot on and I am in the medication safety business. I actually signed up for an account just to quote ISMP. They have staff that have very practical knowledge (i.e. still working or visiting many places around the world) and do tremendous amount of research and site visits before they make recommendations like that. Many times they also use outside staff as consultants too because I am one.

The truth is that unnecessary dilution is very hazardous and I for one, would worry that the diluent was not correct and/or transferring into another container introduces another failure mode. We have lots of old wives tales in my business, so although I can appreciate them, I go for the evidence. Re: morphine streak, one wonders if that was impending thrombophlebitis related to infusion or some HAI.

Re: morphine streak, one wonders if that was impending thrombophlebitis related to infusion or some HAI.

No it wasn't. Are you for real? HAI??? One does not wonder what you wonder. Misguided musings like yours are not helping one single thing in acute care.

Critical thinking is overrated, I know.

Specializes in Medical Legal Consultant.

I would recommend you follow your facilities policies and procedures. If for some reason there is none, then suggest that they be written.

Nurses dilute meds every time we push them into a running line.

Extremely common in the ER.

If you have a bolus running at a liter an hour, pushing a drug over 1 minute will mix it with 16 ml ns (or whatever).

If I want to give something slowly, I might draw up the med in a 5-10 ml syringe, hook to a luer lock, draw in some saline and push slowly. Can anybody think of how that would be more hazardous than pushing the drug out of a 1 ml syringe into a running line?

And- other than diazepam, what shouldn't be diluted?

had a nurse tell me i need to dilute the 1mg of dilaudid i am pushing into a PICC line, because "it's too close to the heart"...

another 1 told me it will drop the blood pressure alot, if you give it "straight up"

Wow...

I was taught to use 10ml syringes for central lines due to high PSI with smaller syringes. Is that no longer current best practice?

I will also dilute for the patient's comfort with peripheral IVs. For example, many people complain of burning when ketoralac is administered straight up, so I'll usually add a few ml to dilute it. With infusions, if a patient can tolerate the extra fluid, I will sometimes y-site meds that frequently cause pain like potassium.

And there are always those doses that are just so small it's impossible to push them slowly; those get diluted, too, unless I have fluids running to push the meds in slowly for me (which I suppose is another way of diluting them).

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