mag sulfate bolusing

[Buggs]

I work on a Mother/Baby Unit. We do take care of many Mag sulfate pts--usually PP with PIH. Very rarely AP's on Mag. The Mag is USUALLY started in L&D. But at least 2-3x in the last year I have heard co-workers who have bolused the pts on the floor. The other day an AP PIH was bolused on our unit then transferred to another hospital where they would probably deliver her d/t the PIH. To the best of my knowledge we have not been trained to bolus the Mag--it was not in MY orientation. We carry at least 4 couplets, even if one of the moms is on Mag. Sometimes we have 5 couplets, and some of us have even experienced carrying 6 couplets. Anyway the nurse caring for the patient had 3 other couplets, had to do the bolus and transfer. I think that is too much. They are setting the stage for a mag sulfate scare at our hospital. Wondering if any of you bolus Mag on the M/B unit, what monitoring is done on mom and if AP what, if any fetal monitoring? After reading the sad story of the maternal demise from Mag, I have to wonder why there are not National Standards for Mag? Why do some hospitals provide 1:1 nursing and others carry Full assignments? Why is there no JACHO standards for Mag or AWHONN standards for Mag? When there is such a range of how to care for these pts shouldn't someone narrow the gap as to what is SAFEST, not what works best for the staffing of the unit? And, back to fetal monitoring, should that be done during a bolus? We aren't trained in fetal monitoring....ARGGGG Thanks for listening.

[HappyNurse2005, RN]

Well, our mother/baby does NOT do mag patients. they don't do any unstalbe patients. the PP pt's on mag stay on L&D until mag is turned off.

We have 2 nurses verify settings on mag bolus/drip changes/starting of mag infusions. constant pulse ox monitoring. BP's every 2 hours. DTR's/lung sounds every 4. Respirations every hour.

[Buggs]

We do q 1hr VS, DTR's,I/O on PP pts, on AP PIH also Q1, FHR q 4. I think q4 for the "stable" PTL AP on Mag.

[enfermeraSG]

Well, our mother/baby does NOT do mag patients. they don't do any unstalbe patients. the PP pt's on mag stay on L&D until mag is turned off.

We have 2 nurses verify settings on mag bolus/drip changes/starting of mag infusions. constant pulse ox monitoring. BP's every 2 hours. DTR's/lung sounds every 4. Respirations every hour.

Same here, no Mag on AP or PP. We also do all the above, except that BP is q 15 just like for epidurals, and DTR's, lung sounds, recording vitals, and I/O's q hour. Everything double checked with another RN when beginning the bolus too. SG

[JaneyW]

Your patient should ALWAYS be 1:1 during the bolus. I have worked at places where the VS were q5 minutes during the bolus and then backed off to q15 for an hour and then q hour. It shouldn't just be 1:1, you should physically be in the room for the bolus time--not leaving the bedside until the pt is stable on the maintenance drip. Your worries are justified. Do you have continuous pulse ox?

[HappyNurse2005, RN]

oh, and of course-i forgot, we also do strict i&o, and although its not official policy, all the docs limit IV fluids to 100cc/hr while on mag.

[HappyNurse2005, RN]

Same here, no Mag on AP or PP. We also do all the above, except that BP is q 15 just like for epidurals, and DTR's, lung sounds, recording vitals, and I/O's q hour. Everything double checked with another RN when beginning the bolus too. SG

well, we do have mag on antepartum, but, antepartum is a part of labor and delivery, staffed by labor and delivery nurses, with ratios appropriate for situation. My last mag patient was on the antepartum side, a PTL with twins at 26 weeks, ctx not subsiding, and she was on mag, had a bolus, had another bolus, went up from 2grams to 3 to 4, back to 2 then up to 4 over the course of the time i had her, and she was 1:1.

[Buggs]

We don't do pulse ox routinely on Mag pts. We do check O2 sats on our C/S with all their VS. Seems our monitoring of C/S pts have become more frequent since there was a bad outcome with a surgical pt on another floor and since a c/s is post-op they have same VS checks as all the post-ops in the hospital. I am afraid the Mag checks and assignments won't change til there is a bad outcome. This is so frustrating!!! I think the double check for Mag is great, we do it for our PCA pumps. One would think Mag is just as potentially dangerous as Morphine/dilaudid. I will bring all this up with our Nurse educator for some clarrification. If the pt needs bolusing and they don't want to transfer her to L/D, maybe an L/D nurse can come and care for her on the floor til stable on the maintenance. What about fetal monitoring, is this needed during the bolus?

[Jolie, BSN]

Quote from Buggs, "I am afraid the Mag checks and assignments won't change til there is a bad outcome."

Sadly, you may be correct. Many hospital aministrators fail to understand the specialized (and potentially dangerous) nature of so many treatments and medications used today, not only in OB, but in every hospital department. Because most outcomes are good, regardless of the quality of care, they cut corners and place patients (and nurses' licenses) at risk.

But please do your best to change this by contacting the hospital risk manager, and providing him/her with AWHONN standards of care.

Good luck to you, and thank you for taking steps to correct this unsafe situation.

[HappyNurse2005, RN]

What about fetal monitoring, is this needed during the bolus?

i dont know if this is specifically stated, but, usually if they are sick enough for mag, they are sick enough for continuous monitoring

[Buggs]

Did some checking...the bolus is done over a half hour (4gms) and vs are done q 15 min during bolus. fetal monitoring only if pt is contracting(Mag for PTL vs PIH) Seems no one but me is concerned with carrying a full M/B assignment and doing a Mag bolus. Also, do not have to stay in room for bolus. After bolus vs/assessment done q1hr and while we carry 3 other couplets. I seem to be alone in my concerns with this practice.

[AF-NRS]

Every hospital i have worked at has had the same Mag protocol---done only on labor and delivery and must have continues monitoring of both maternal and fetal heart rate, VS q5min during the bolus itself and then q15min X4, q30X2 and then hourly for the remainder of mag maintenance. mom has to have a pulse ox on her through out as well---you must have calcium gluconate at the bedside in case of mag toxicity.

This is a 1:1 ratio. The current practice at your facility is an accident waiting to happen.....