Giving pain meds to SCD during warmed fluid infusion

[Sammieee]

I care for many SCD patients  (sickle-cell) with acute pain crisis. My facility states that we begin them on warmed maintenance fluids to assist with pain control. The way this is set up is the MIVF are infusing through the pump, and at the end of the tubing it is connected to (primed) warmed tubing, which is then directly connected to the patient. The warmed tubing does not have any ports on it.

Yesterday I had one of these patients requiring dilaudid q 30 mins/1hr. I checked the compatitibility of the fluids/meds and verified with pharmacy that is was OK for the dilaudid to go through the warmed fluids. Because I checked these compatibilities, I felt comfortable pushing the dilaudid (slowly, and diluted in 10 cc of NS) through a port in the IV tubing set (the port closest to the patient, which would still need to travel the length of the warmed IV tubing set, since there are no ports on the warmed tubing).

I justify this because I was sure to check compatibilities prior and since the pt was requiring q30min dilaudid doses, it would increase risk of contamination and be slower/less efficient to disconnect the fluids from the pt, stand there for 5 minutes slow-pushing the dilaudid, then a NS flush, then reconnecting the warmed fluids.

I explained the set-up to my charge nurse, who stated not to do this any further and then felt the need to tell other nurses on the unit that I messed up.

Looking for feedback on the correct way to do this and, while I'm confident my setup was not a patient safety issue, is there is a better way to accomplish this task. Thank you.

[JadedCPN, BSN, RN]

Your best option is going to be looking at your facility/unit’s policy and procedures to determine what is the appropriate and expected method.

[chare]

Not knowing which device you used and what your policies/procedures allow, but I don't see why this wouldn't work.  Have you asked your charge nurse why he or she felt that this wasn't correct?

[JKL33]

I have no idea why this is a mess-up. Sounds fine to me unless there is some obscure things in your policies.

It's really too bad but you've learned something about this charge nurse. His/her behavior was inappropriate and s/he is a bit of a trouble-maker. Keep that in mind going forward.

[Lunah, MSN, RN]

Did your charge give you feedback as to what the preferred method would have been? I assume the disconnect/push/reconnect? That seems silly and I would ask for the basis in evidence, starting with policies and seeing what is cited there. Good job verifying with pharmacy, always smart to use your resources. 

[203bravo, MSN, APRN]

I never agree with discussing 1 employee to others --- always wrong.

But there may be some legitimacy to the charge nurse's admonishment. Manufacture details for handling the medication are clear that it should not be exposed to temps > 86f. If the warmer is set to a temperature higher than 86 then the should be some cause for concern. (however, there are a number of published studies that show dilaudid remains stable at temps up to 98f.)

[MunoRN, RN]

16 hours ago, 203bravo said:

I never agree with discussing 1 employee to others --- always wrong.

But there may be some legitimacy to the charge nurse's admonishment. Manufacture details for handling the medication are clear that it should not be exposed to temps > 86f. If the warmer is set to a temperature higher than 86 then the should be some cause for concern. (however, there are a number of published studies that show dilaudid remains stable at temps up to 98f.)

If dilaudid can't be exposed to temps of >86f then it should never be given to a living human, or at least one with a reasonably normal core body temperature.  

[JKL33]

22 hours ago, 203bravo said:

Manufacture details for handling the medication are clear that it should not be exposed to temps > 86f.

Storage and handling involves things like transportation and actual storage. Don't unload these pallets and leave them out in the heat or store them next to the boiler or whatever, etc. Many medications have similar storage and handling instructions. If the instruction was meant to involve the short term of administration then that information should be noted under "administration."

My faith in this charge nurse knowing random obscure information from a package insert is low anyway. If that's what she was basing her opinion upon she should have stated it.

[203bravo, MSN, APRN]

3 hours ago, JKL33 said:

 

My faith in this charge nurse knowing random obscure information from a package insert is low anyway. 

Yeah... I had the exact same thought  :)