mixing pain medications with a flush

[painmeds]

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?

[turtlesRcool]

In Nursing School, the rule I was taught was to administer IV Morphine 1 mg per minute. I had to deliver a 10 mg dose and my instructor made sure I knew exactly how I was going to administer the dose. Drawing the dose up in a 10 mL syringe allowed me to give 0.5 mL each 30 seconds (do the math). Furthermore, it is important to flush at the same rate that you administered the drug, so I flush with a 10 mL syringe of Normal Saline at 0.5 mL every 30 seconds. I have worked at hospitals where a nurse gave the IV push medication slowly, then slammed the flush in quickly, which made the patient vomit because all the medication in the IV line was then "shotgunned" into the patient's system. And remember that Dilaudid is considered seven times more potent than Morphine, so we should deliver it *at least* 5 minutes per mg. If a patient complains you are pushing the drug too slowly, the patient is savoring the quick intoxicating effect.

So, your nursing instructor expected you to spend 20 minutes pushing that one dose of morphine? And by your math, I should spend 40 minutes giving 2mg of IVP Dilaudid (20 for the push and 20 for the flush)? Um, maybe if I were doing private duty nursing this might work, but on a busy med-surg floor this would put me so far behind that my other patients' scheduled medications would be late that they would be med errors.

I do commend you for wanting to be cautious with IVP pain medications, but in the real world it is important to balance that with your other patients' needs.

I do agree with your regarding the need for slow flushing.

[JKL33]

Here's an example of how/why people have historically done things in manners that vary all while believing they were using sources that relied upon manufacturer recommendation. Morphine sulfate entry:

IV Administration

IV: Solution is colorless; do not administer discolored solution.

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

Rate: High Alert:Administer 2.5-15 mg over 5 min. Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.

I find this to be pretty typical of entry information I used to see when using various drug guides over the years (slight variations between guides/publishers) - with this exact kind of inherent leeway. Even though we're mostly/frequently using guides that interface with eMARs now (and not this particular one, at that), I think, very generally-speaking, that this is decent proof of how and why the general medication safety community needs to tone down some of the insinuations they've made about why nurses do things.

ETA: I have posted this believing that this is an up-to-date entry and is not information from a years-old printed resource.

[turtlesRcool]

Smaller syringes use more markings for the same volume, so I'm not sure why it would be significantly more difficult to push slowly using a smaller syringe. 1mg over 2 minutes is 1mg over 2 minutes, whether that 1mg is in 2mls or 10. So if you're trying to go one mark per 15 seconds, for instance, that's the same with either concentration since you're using a smaller syringe for the undiluted injection.

This is true if you are adding the medication to a line with fluids running.

But if you are pushing a small amount into a saline lock, most of the drug will still be in the IV. This is especially true if you are pushing something like 0.25ml of dilaudid, where you might have all of the medicine in the line, not the patient when you finish your "push". At that point, the medication would actually reach the patient's vein through the push that follows. And if you're using the standard 10ml flush, now you're pushing the same 0.25ml, but you don't have the smaller markings on your syringe as it enters the patient. Diluting the original medication means that you will be administering the medication during the push and the flush rather than just during the flush.

[morte, LPN, LVN]

I'm not sure how it's particularly different since the distance you're having to push the plunger over the 2 minutes is essentially the same whether we're talking 10ml in a 10ml syringe or 2 ml in a 2 or 3ml syringe (you're pushing each one about an inch a minute). If you're trying to slowly push 1ml using a 10ml syringe then I get it, otherwise it wouldn't appear particularly different given the similar plunger lengths.

should not be using smaller syringes.

[josbarRN]

In response to "So you spend 40 minutes pushing 2 mg of IV Push Dilaudid?" No, I have never spent 40 minutes giving a med IV Push.

I realize it can seem to take forever; fortunately, there are ways to lighten your load: if the patient has maintenance fluids going that are compatible, you *can* administer the IV Push drug through the same access port you would use for an IVPB med and program the pump to deliver 10 mL of fluid, which will take care of your syringe instead of having to stand at the patient's bedside throughout the administration. The patient will get the prescribed dose over a safe amount of time as the med diffuses in the maintenance fluid.

I know we nurses are busy and sometimes overburdened and "Chart as you go" is also an unrealistic expectation so we find shortcuts where we can. I would still not give 2 mg of Dilaudid any more quickly than over ten minutes. As far as the flush, remember that a PIV only needs a 3 mL flush, so I don't have to flush a whole 10 mL for a PIV. With a central line that requires a full 10 mL flush, yes, I still flush slowly.

By the way, while you are pushing your IV med slowly, this isn't a bad time to *talk* with your patient. We are encouraged to connect with our patients. During this time, I might ask general questions about their life outside the hospital. After all, our goal is to get them out of the hospital to the next phase, whether that be going home or to another facility. Talking with my patient helps keep them focused on today's plan of care: ambulating, procedures, etc. I also take this time to discuss with them risks associated with Opiates, such as Constipation and I discuss mobility, last bowel movement, etc. This is a *great* time for Patient Education and my patients have fewer questions at the end of the shift when I am handing off to the next nurse. My patients understand why we monitor blood pressure, respirations, etc. and they appreciate being well-informed. Being informed also provides your patients with a sense of being part of their treatment instead of feeling everything is being done *to* them. When patients come to the hospital, there is a great deal of control that they give up...this is one way to give that sense of control back to them.

I also discuss with my patients that, if they have PO pain medications, why we will want to administer the PO medication when it is available and have the IV medication as a backup for breakthrough pain, since our ultimate goal is to manage their pain with a med they will be able to take at home. Yes, I would *much* rather give them a pain pill which only takes a few seconds...I want to get out of there and get to my next patient, too, but if you are frustrated and impatient, it will show in your mannerisms.

I do end up staying after my shift to catch up on charting more often than I care to, but Patient Care comes before charting, in my book.

[Susie2310]

should not be using smaller syringes.

Are you referring to a peripheral IV or a CVC?

[MunoRN, RN]

This is true if you are adding the medication to a line with fluids running.

But if you are pushing a small amount into a saline lock, most of the drug will still be in the IV. This is especially true if you are pushing something like 0.25ml of dilaudid, where you might have all of the medicine in the line, not the patient when you finish your "push". At that point, the medication would actually reach the patient's vein through the push that follows. And if you're using the standard 10ml flush, now you're pushing the same 0.25ml, but you don't have the smaller markings on your syringe as it enters the patient. Diluting the original medication means that you will be administering the medication during the push and the flush rather than just during the flush.

You would go halfway between the 10 and 9.5 marks on the flush for 0.25ml, I'm not sure that's really excessively complicated for a nurse to be able to figure out.

[MunoRN, RN]

should not be using smaller syringes.

You shouldn't initially assess for patency with a smaller syringe, but was patency has been confirmed there is no reason not to use a smaller syringe.