IV Magnesium Sulfate in office???

[Anagray]

Is it safe to administer 1 gram IV over 30 minutes to migraine patients with no monitoring and no baseline levels?

Having a meeting today with our supervisor to disuss this.

If you know of any documentation I can present to defend our point of view, please let me know!!!

Thank you .

[PMFB-RN, RN]

What are you worried is going to happen? That is a small dose and given very slowly. I would give mag sulfate IV in an office enviroment without a second thought. There is a reason we have RNs to administer IV medications.

[PMFB-RN, RN]

I feel that office and hospital are completely different settings as far as patient safety goes.

*** They certainly are. However when the OP is asking about is very, very low risk. Appropiate for an office staffed with an RN to administer the mag IV.

[Vespertinas]

When you say patient safety do you mean... support in case something goes wrong? Or equipment you need to monitor a patient?

If you're worried about something going wrong... well, I think we've addressed that there is minimal risk. Really, I think your biggest concern should be phlebitis or extravasation. That can definitely be painful so run slowly if pt reports burning and keep an eye on the IV. If it happens anyway, stop the IV, apply a cold compress (or whatever intervention the MDs support in the protocol), elevate. You're looking for more support but you ARE the support and you can manage this.

If you're worried about equipment to monitor... well, I think we've also addressed that it's not really necessary.

What else does a hospital have that you feel like you might need?

[Jolie, BSN]

I understand the hesitation to begin a new aspect of care, especially if you believe that there has not been adequate training and/or there are not clearly defined (and evidencce based) policies and procedures in place.

Is your office staff currently providing IV infusions of other medications? If not, has there been an opportunity to brush up on IV start skills, current equipment, fluid recommendations and medication compatibilities, etc? This may be a good starting point.

If you are already skilled and current on IVs in general, then specific training on this particular medication is in order: Targeted patient population, indications and contraindications, mechanism of action, anticipated effects, side effects (and management of them), safety considerations, post-infusion care, discharge instructions & follow-up.

Next comes training on the actual procedure itself. Run thru a mock set-up. How will the medication be supplied? Will you use pre-mixed stock (highly preferable), or will 2 nurses have to prepare and sign the mixture (high risk for error)? Will you establish a primary IV with a running fluid, or start a saline-lock? Will you use an infusion pump with free flow protection, or a syringe pump? One or the other is a must to prevent inadvertent overdosing, which is probably the greatest risk. What is the protocol for vital signs (and O2 sats) pre, during & post procedure? What other medications (if any) will be part of this protocol and how will they be administered? Will there be a dedicated flow sheet (or page in the EMR) to document this care, or must the nurse write narrative notes? How long is the recovery period before the patient may be discharged? Must s/he have an escort, or be allowed to leave/drive home alone?

In the unlikely event of a serious adverse reaction, what is the mechanism for summoning help and who will respond? Do you have an emergency or code team within your office, or are you part of a larger medical center campus with a team that will respond to office emergencies? Must there be a physician/APN in office at all times during MgSo4 infusions, or can they be given when the office is staffed with nurses and support staff only? What is the role of medical office assistants in this procedure, if any?

Then comes the actual integration of this care into your office setting. How will these patients be scheduled? How will staff be assigned? How much time should be blocked for this patient? Where will this service be provided? Do you have a dedicated "infusion" room that will be consistently stocked with all of the necessary supplies and emergency items? I can tell you from OB experience, when "misadventures" occur during potentially high risk procedures, it is often because someone decided that it was "no big deal" to do said procedure in a location other than a dedicated, well-stocked procedure room. When something untoward happens, the necessary suplies are not available at one's fingertips and the **** hits the fan.

I agree with the other posters that this service can be provided in the office setting, but recognize and agree with your well placed concerns that adequate training and preparation must come first. I think we all have been unnecessarily put in bad situations because of other people's bad planning, or complete lack thereof. Good for you for trying to avoid that here!

[Jolie, BSN]

Most of the literature pertaining to complications of MgSO4 infusions comes from OB, where a search will provide plenty of examples. To summarize, serious complications are most often tied to human error, and not necessarily the medication itself. Improper mixing, labeling, and inadvertent free flow leading to massive overdoses are usually the culprits. I would strongly encourage you to devise policies and procedures that minimize these risks, such as using only pre-mixed stock solutions, clearly labeling primary and medication IV lines, utilizing IV pumps with free-flow prevention or dose-limited syringe pumps to administer the medication, providing 1:1 nursing staff during the infusion with frequent vs assessment, having necessary emergency medications and equipment available in the infusion room (including calcium), and having a well practiced plan in place for emergency response.

[monkeybug]

Have you tried daily PO magnesium?

No. I've discussed it with my neuro a couple of times, but he said that I would have to take a whole lot of po to make any difference in my symptoms.

[morte, LPN, LVN]

I would wonder why the mag works, if you are def., it would seem you would benefit from supplementation. mag delay or mag 64.....maybe it would only lessen and not "cure"?

No. I've discussed it with my neuro a couple of times, but he said that I would have to take a whole lot of po to make any difference in my symptoms.

[CrunchRN, ADN, RN]

Great post Jolie!

[Altra, BSN, RN]

When I give Mag in the ER it is most often a component of treatment for varying degrees of respiratory distress. 1g given over 30 min. ... 2g given over one hour. For severe asthmatics who we are REALLY TRYING HARD not to intubate, I've run it in faster -- that was in fact protocol at one hospital where I worked.

I can sense your genuine concern in your posts, OP, but I'm not understanding the basis of your concerns. And I bow down and applaud office practices which are willing to employ appropriate staff to perform these interventions in an office setting, rather than the all-too-often default mode of many PCP offices, which is: go to the ER.

[monkeybug]

I can sense your genuine concern in your posts, OP, but I'm not understanding the basis of your concerns. And I bow down and applaud office practices which are willing to employ appropriate staff to perform these interventions in an office setting, rather than the all-too-often default mode of many PCP offices, which is: go to the ER.

^^This!!

My physician spends most of his office hours running infusions on patients in an effort to keep them out of the ER. Most ERs undertreat/mistreat migraineurs (I've been told "Headaches don't get IVs!). It costs me an arm and a leg every time I go, but so worth avoiding a trip to ER hell.

[Sadala, ADN, RN]

^^This!!

My physician spends most of his office hours running infusions on patients in an effort to keep them out of the ER. Most ERs undertreat/mistreat migraineurs (I've been told "Headaches don't get IVs!). It costs me an arm and a leg every time I go, but so worth avoiding a trip to ER hell.

I agree with you. While I've had really, very excellent luck with hospital ERs in relation to my migraines, my fond hope and dream is always to manage them outisde of that setting. ER free for the past three years but it isn't always easy, and any new modality that might work is great.

[evolvingrn, BSN, RN]

As we become more accountable this will be come more common practice. an ER is not an appropriate place for migraine. its not cost efficient , much better to manage that in an office setting.