IVP pain med safety

[Swellz]

There's an ongoing to push or to hang piggyback issue on our floor. We're telemetry/oncology, but not necessarily all of our patients are on tele. I was told when hired almost two years ago that we don't IVP pain meds, we only IVPB, and never questioned it. There's a rumor going around that our clin spec is saying we can IVP if we are ACLS certified, which doesn't seem right to me. I'm following up with her and my NM, but I wanted to see how it's done elsewhere.

When asking my more experienced coworkers, a few of them IVP'd on other floors/hospitals, and are totally comfortable with it. Others are not comfortable, especially not with a patient off the heart monitor. But according to every order, we have to document a RR q15x2 anyway. So, you're pushing it over a couple minutes and watching your patient, then coming back every 15 min x2... that's pretty close monitoring if you're doing what you're supposed to do. I can't find a policy on any of this, and I'm sure if I call pharmacy they will say how the medication can be administered, not necessarily how it should/could be administered.

When I did an AN search, it looks like everyone is pushing except us, but it isn't specified whether this is on tele-monitored floors or not.

Do you IVP pain medicine? If so, do you do so on non-monitored patients?

[MunoRN, RN]

I've only ever heard of nurses putting a pain med push into a minibag and hanging it as a secondary in threads here, I've never actually seen it done, much less seen it as a standard practice on any unit. Cardiac monitoring is actually one of the least effective ways to monitor for adverse effects related to opiates so I'm not sure why that would be considered a requirement.

I don't really get the purpose of it, if you already have a primary fluid line, or are setting one up for this purpose, why does it help to put it into a bag and hang it as a secondary? If the goal is to infuse it slowly, it can be infused just as slowly by putting it into the line and setting the pump appropriately.

[dexm]

I work in the ICU, and have bags of fentanyl, versed, etc. hanging "unsecured" when a patient is on a continuous gtt for pain/sedation. The only pumps that require a key to access are the PCAs and epidurals. All other narc infusions hang on the pole just like NS and IVPBs. I've never thought about the security of that before now, but as far as I know there haven't been any incidences of someone grabbing a bag of fentanyl off the IV pole and running out (at least at my hospital).

[Here.I.Stand, BSN, RN]

I work in the ICU, and have bags of fentanyl, versed, etc. hanging "unsecured" when a patient is on a continuous gtt for pain/sedation. The only pumps that require a key to access are the PCAs and epidurals. All other narc infusions hang on the pole just like NS and IVPBs. I've never thought about the security of that before now, but as far as I know there haven't been any incidences of someone grabbing a bag of fentanyl off the IV pole and running out (at least at my hospital).

It probably would happen at mine. We've had staff accosted outside, asking if we had anything for sale. We've also had gang activity right outside the hospital, including revenge attempts for cronies who happen to be inside. Most of us have two patients, plus we take breaks and leave the rooms to get stuff or run labs, so the RN doesn't have clear site of the drug at all times.

Fentanyl and Dilaudid gtts are put on a PCA pump--the only difference is the settings and the lack of a PCA button--the cartridge is locked to the pump. Our pharmacy mixes Versed gtts; the bag is placed inside a clear plastic locked box with a hole in the front so we can adjust the gtt. Same thing with epidurals; if it contains fentanyl, the bright yellow epidural box must be locked.

[BloomNurseRN, ASN, BSN, RN]

This is a bit mind boggling to me. I've pushed Dilaudid or Morphine almost every shift I've ever worked and I'm just on a regular old Med-Surg unit. We get a lot of post-op and they regularly receive Dilaudid. We also end up with palliative care and many receive even up to 2 mg every 30-60 minutes. Most of those people aren't on tele at the time. Definitely not a policy I am aware of or have seen before.

[VANurse2010]

There seems to be a trend recently where everything beyond really basic nursing is called a "critical care skill." And then facilities wonder why and get pissed when their M/S nurses don't know how to do anything...

[VANurse2010]

I work in the ICU, and have bags of fentanyl, versed, etc. hanging "unsecured" when a patient is on a continuous gtt for pain/sedation. The only pumps that require a key to access are the PCAs and epidurals. All other narc infusions hang on the pole just like NS and IVPBs. I've never thought about the security of that before now, but as far as I know there haven't been any incidences of someone grabbing a bag of fentanyl off the IV pole and running out (at least at my hospital).

My hospital used to have free-hanging bags of sedatives/analgesics in the ICU, until they uncovered a massive diversion scheme (essentially perpetrated by a single nursing supervisor). The drips are now on special pumps with a lock.

[Here.I.Stand, BSN, RN]

My hospital used to have free-hanging bags of sedatives/analgesics in the ICU, until they uncovered a massive diversion scheme (essentially perpetrated by a single nursing supervisor). The drips are now on special pumps with a lock.

No kidding, that would be super easy to siphon some off I'd think

[Here.I.Stand, BSN, RN]

I don't think our doses are crazy. It's normally 1 or 2mg q4, although of course some people need more.

How much do you push?

The docs where I work right now generally don't Rx morphine; I think we pushed up to 4 mg at my old hospital when I worked there. Dilaudid is generally from 0.4-1 mg (depending on opioid tolerance, pain level, size, etc.) q 2 hrs; Fentanyl is generally 25-100 mcg. Most of our patients (SICU) are also on a CADD; these doses are in addition to 25-200 mcg/hr infusions in the case of fentanyl. Can't remember the standard range for Dilaudid offhand; our MDs prefer fentanyl.

In the LTACH I worked in, Almost all of the IVP pain meds were Dilaudid. 2-4 mg q 2 hrs was a very common dose because these were often people who had been in the hospital and receiving pain meds for months so had built up tolerances. One burn patient got 200 mcg Fentanyl and 2 mg Versed before and halfway through her dressing changes. Patients there may or may not have been on tele, but pain med status didn't make that decision.

The largest dose I've ever pushed was 20 mg of Dilaudid--yes, that said twenty. This was a non-monitored floor, and the pt was up and around ad lib. He came in for sickle cell crises and was VERY tolerant.

As other posters have said, the monitor really doesn't add safety in this case.

[Wile E Coyote, ASN, RN]

If we're talking Morphine or even Dilaudid, your parameters are very standard. If your unit was giving unusually large doses it would at least explain your leadership's safety concerns (explain, but not necessarily justify). If I felt compelled to use technology to monitor narced floor patients, I'd put my money on EtCo2 and SpO2, btw.

[Swellz]

I appreciate everyone's input! I'm pretty baffled by how many of my coworkers were like me and simply didn't question it. Fortunately, my CNS already contacted her supervisor regarding a change in policy so we can push on our sister unit. Unfortunately, the conflict has already begun; another nurse was told that she better not start pushing because nobody else will and she'll "ruin things for everyone else".

[melizerd, ASN, RN]

I work on an oncology med/surg floor and we routinely give a lot of IV pain medication, especially to those people with cancer. Almost none of them are on tele. Last week I had a patient who was getting 4mg of IV morphine q3, it's a pretty common dose for us. We do also have morphine drips for comfort care/hospice patients.

We do a lot of drips though that I've heard other med/surg floors don't always do like caridizem, insulin, and heparin. So I guess it's what you're used to doing and you get more comfortable the more you do it.