How much Versed/Fentanyl is too much????

GHGoonette, BSN, RN · Mar 4, 2011

Hi, aren't you a student CRNA? If so, you probably know more about this than I do :) That Versed dose sounds incredibly high (we call it Dormicum), the maximum I've ever seen administered was 15mg. However, the Fentanyl dose is definitely not unheard of. Yesterday we had a patient on the table for just under 5 hours; the anaesthetist administered 5 of the 100mcg/ml ampules. Off the cuff, I can't remember seeing higher doses, but I should imagine it's entirely possible, especially if the patient has a history of substance abuse.

In PACU, the only "adverse effects" I've seen are when the patient takes ages to wake up, but that's usually due to getting additional opiates like pethidine or morphine intra-operatively (and both of these frequently cause a reaction when administered IV.)

LegzRN · Mar 4, 2011

once had an er doc that would consistently write "Fentanyl 50mcg iv q 15min x3 if necessary"

He would often say that when he wrote that he meant "Fentanyl 50mcg iv q 15min until not whiny anymore"

catshowlady · Mar 4, 2011

I'm ICU, not PACU or OR. We use Versed & Fentanyl gtts to maintain sedation in intubated pts.

That said, I have given up to 300mcg/hr of Fentanyl and, oh, around 33mg/hr of Versed. We dose Versed in mg/kg/hr, and we max out at 0.12mg/kg/hr. So a larger pt will get more Versed than a smaller one. I have hung both concurrently, at the max rate on the fentanyl and near max on the Versed. I have also hung max rate of Versed concurrently with max rate on Propofol, which for us is 50mcg/kg. This was on a large pt, and we were hanging new bags of Versed about q3h and new bottles of Propofol about once an hour (this was during the propofol shortage, and all we had were 50mL bottles).

As far as side effects of higher doses, I think the folks who are on Versed for a couple of weeks for a prolonged intubation, esp at higher doses, seem to take longer to wake up when we turn it off. JMO.

:paw:

Da_Milk_of_Amnesia, MSN · Mar 4, 2011

With Fentanyl you can get chest wall rigidity and obviously high Peak pressures. We had a guy that had this one, and it wasn't pretty to watch.

nerdtonurse?, BSN, RN · Mar 4, 2011

I'm like Catshowlady, I work in an ICU. As long as it's not dropping the pt's pressure (they're on a vent, so it's not like we've got to worry about the airway emergently), follow the protocol at your facility. We've had people on Versed drips, weight based application -- you get someone who's addicted to narcotics or a serious alcoholic, regular sedation doesn't even phase them (*80+ Diprivan, and they are wide awake), they're yanking out ET tubes and trying to crawl out of bed, swing at you, etc. Big thing with a versed drip that I've seen is don't cut them off cold turkey if they've been on one for a long time....they go into withdrawl. We step the dosage down by 1/2 each day until we can safely DC the med. We had one guy broke a nurse's jaw with a single punch because he woke all the way up when they cut off the Versed. It reminded me of when we have to give Narcan -- these folks wake all the way up, and they are PO'd at the world.

SleepynurseRN · Mar 5, 2011

Thanks and good point. You definitely have to wean them off slowly.

SleepynurseRN · Mar 5, 2011

Hmmm never heard of those adverse effects. My facility is tweaking their weaning/ sedation infusion protocol and I'm on the EBP committee for it. Thanks for the insight.

sunnycalifRN · Mar 5, 2011

Hey everyone, this is my 1st time posting and I have a quick question: What's the highest dose of Versed/Fentanyl you've ever seen a patient receive? Currently my highest rate is 33mg/hr of Versed and 225mcg/hr of Fentanyl
Also, anyone know any documented adverse effects effects of such high infusion rates?
Thanks guys!!

We had a patient on comfort care with a high narc tolerance. His fentanyl drip was running at 2500 mcg/hr!! That's the highest dose I've ever given.

Dodongo, APRN, NP · Dec 21, 2012

I've seen 15 of versed and 450 of fentanyl. Plus he was being paralyzed with vec.