IV Fentanyl use on Med/Surg Unit

Nurses Safety

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I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?

If you push it too fast it can cause respiratory paralysis, and of course large amounts are dangerous. But, if you have a patient in so much pain that you are pushing Fentanyl I assume you are not going to be leaving them alone anyway, until the med has taken effect and the pain is under control. Plus all nurses need to be aware of precautions before giving any med. I think that metoproplol IVP can be just as dangerous if you just push it and walk away, but that is a common med on our MS unit.

We rarely use Fentanyl IVP, usually it is in a PCA in small frequent doses, or a continuous drip. Works very well for us that way.

I think it is about being conscientious about your medication. You certainly wouldn't want to throw this stuff in like its some adenosine. I spoke with a floor nurse friend of mine who stated that she will either push it in increments over 2-5 minutes, or set it in a 100 cc bag and run it in at 20 cc/min.

I have seen MS and a variety of other things cause almost instantaneous respiratory collapse too, but that doesn't mean we refuse to use it now. You simply have to take precautions. That is a risk of the medication that the prescribing clinician has decided is outweighed by the potential benefits. I administer all of my schedule II narcotics personally and always keep a dose of naloxone in my shirt pocket when doing so. I mean, the stuff is cheap, it doesn't have to be refrigerated, and when those unexpected things do occur, they can easily be reversed.

PS I exclusively use fentanyl in intravenous form for major trauma patients who may have some undetected hemodynamic compromise. Much better hemodynamic profile than MS or hydromorphone in my experience. If they have significant respiratory compromise, I'll just throw in a little more and some lidocaine and succinylcholine, then drop a tube. I have only had to do that three or so times, and they would have all ended up with a tube anyway because they were getting shipped out on the bird, and those folks snow and tube everybody!

I think it is about being conscientious about your medication. You certainly wouldn't want to throw this stuff in like its some adenosine. I spoke with a floor nurse friend of mine who stated that she will either push it in increments over 2-5 minutes, or set it in a 100 cc bag and run it in at 20 cc/min.

I have seen MS and a variety of other things cause almost instantaneous respiratory collapse too, but that doesn't mean we refuse to use it now. You simply have to take precautions. That is a risk of the medication that the prescribing clinician has decided is outweighed by the potential benefits. I administer all of my schedule II narcotics personally and always keep a dose of naloxone in my shirt pocket when doing so. I mean, the stuff is cheap, it doesn't have to be refrigerated, and when those unexpected things do occur, they can easily be reversed.

Except in the case of fentanyl induced chest wall rigidity which can only be reversed through the use of muscle relaxation (paralysis). Note this also requires the placement of an endotracheal tube in most cases. Which it sounds like you can do (PA-C), but there are others who lack that training.

If Fentanyl is used in PCA or in an epidural infusion on your med surg floor what is the concern if it is ordered IVP. Whats the difference between a PCA IV bolus and an IVP?

To me all the pump is doing is pushing the Fentanyl into a running IV instead of the RN pushing it. Same drug, same doses same potential for side effects?

That said if your argument for not using FentanylIVP is because of its short duration and should be utilized via PCA to assure better pain control that can be a valid arguement. Or if the usual patient load would preclude close monitoring that is another arguement. However, if you are arguing that the patient load is too great to allow for adequate assessment of IVP Fentanyl then I would say it is also to0 high to care for patients with PCA or continuous epidural infusions.

Epidural delivery of Fentanyl is associated with less respiratory depresant effects than IV delivery. Also less respiratory effects than morphine given epidurally.

I work in pacu, fentanyl is our main drug of choice, but I do not think it should be used IVP on a med/surg unit. For one it is too short acting. Why not chose diluadid or something else. Secondly it can cause chest wall ridgidity as mentioned before. Third the dose is very individual. I usually give 25-100 mcgs at a time q5min. prn up to a total dose of 250-500 mcg. Some people can tolerate 100mcg at a time 500mcg total and never bat an eye and still c/o pain. Other people you give 25mcg to X1 and they are apnic and you are stimulating them to breathe or giving narcan. Should only be used if you can monitor 1:1 with pulse ox. for at least 20 min or longer. I love it in the PACU but why chose it for med/surg when you have many other options. :confused:

Specializes in Critical Care,Recovery, ED.

Nilepoc

Your point about epidural fentanyl is well taken. I included epidural infusions as no matter what drug is used epidurally it requires more frequent assessments then the traditional PO/IM analgics thus patient load is more a factor in whether nurses are comfortable caring for these patients.

The California Board of Registered Nursing is clear that CONTINUOUS MONITORING IS REQUIRED.

The RN must not leave the patient and must not have other duties, such as assisting the physician. The patient must be a 1:1 until recovered from the medication. Fentanyl is such a medication. Conscious sedation may become deep sedation or anesthesia so our board protects the best interest of the patient.

http://www.rn.ca.gov/policies/pdf/npr-b-06.pdf

Specializes in Med-surg; OB/Well baby; pulmonology; RTS.
i have never seen it ordered on our med-surg unit. we only see fentanyl in continuous epidurals (with continuous pulse ox and frequent vs) or in a patch.

ditto. we have never had an order for fentanyl iv push. the only time we ever see fentanyl is in an epidural for pain management and we rarely get epidurals anymore: they are usually on a pulse ox and telemetry with vs q 4 hours-at least.

I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?

We give fentanyl via epidural and pca which require q1hr monitoring of pulse ox and pain scale as well as respirations. It is a high level of care. We do not give fentanyl iv push nor do I know anyone who does push it on the floor in the general patient population.I hope you and your peers do extensive research and check with state board of nursing. It is my understanding that the determination for use of fentanyl as analgesia vs analgesia is made by the concentration of the medication. Good look. I will be following your thread to see how others respond.

Hmm. Perhaps my facility is not as cautious with this as they should be. Of course given the incident I described on the floor several weeks back perhaps it IS best kept to critical care areas when given IV . I have seen a lot of Fentanyl IM ordered as a preop med which shouldn't be a problem on the floors. I guess I have looked at it the same way I have looked at Demerol and MS..and have always been very cautious with IV doses of ANY of these.

The California Board of Registered Nursing is clear that CONTINUOUS MONITORING IS REQUIRED.

The RN must not leave the patient and must not have other duties, such as assisting the physician. The patient must be a 1:1 until recovered from the medication. Fentanyl is such a medication. Conscious sedation may become deep sedation or anesthesia so our board protects the best interest of the patient.

http://www.rn.ca.gov/policies/pdf/npr-b-06.pdf

The link addresses conscious sedation, not Fentanyl used for pain management.

I would not be in favor of this. Doesn't JCAHO say that physicians can not write ranges? If they can, then I think your hosp needs a policy about starting at the lowest dose, providing adequate monitoring such as spO2 and vital signs. Until you are sure of being covered in aspects such as this, and given adequate inservice education to show competencies, I would not give this medication.:uhoh21:

I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?

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