25000 mcg of fentanyl in 5 sec

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Specializes in ICU, and IR.

Ok so here is the story I was taking care of an ICU pt, my fentanyl gtt was empty so I was hanging a new bag, 25000 mcg in total bag. I programmed the pump with my dose which was something like 100 mcg/hour. I turn around then I hear this tone as though it had just given a bolus...I turn around and look and my entire bag of fentanyl had been delivered to the patient in all of about 5-10 sec. I immediately called the resp therapist and thankfully the patient was vented so we just switched modes till it all wore off. Here is what I find interesting...I reported the incident and even labeled the exact pump and module (Alaris pump) registered it as a potential fatal event. About 1 week later I get an email from plant operations stating about the pump "could not duplicate problem, put back into service". I fear that this is just going to happen again with this pump and next time it may be more severe. I know 100% I programmed the pump correctly so it was not user error. Is there something more I should be doing?

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I don't know if there is something else you should be doing but thankfully nothing happened to the pt. I had something similar happen to me with a mag piggyback. I program the pump correctly and turned around to do other stuff and 5 minutes later the pump had bolused the magnesium. I showed the other nurse who was in the room the setting and it was correct. So I reported it, I don't know what happened with that pump. Hopefully it doesn't happen again. Sometimes, now I'm paranoid and I watch the pump to see it start and make sure its not going to fast.

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Specializes in ICU, and IR.

Yep this wasn't documented but my charge nurse took the pump with the same settings I had programmed and just put a 500ml bag of saline on the pump. Even though it read fentanyl 100mcg/hour it pumped the entire bag of saline out in no time at all...under 1 minute. I should of had this documented but either way the patient ended up fine and I don't work on that unit anymore.

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Wow... that's one powerful alaris pump. 90 liters an hour.

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Specializes in Rehabilitation,Critical Care.

wow..25K mcgs Fentanyl in a few seconds? Unbelievable.

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Specializes in ICU/PACU.

Wow. I'll be watching the drip rate after initiating from now on. I don't typically do that, but if you glance for a second at the drip chamber you'd see it going as a bolus.

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pump must have a V8 in it

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Specializes in Cardiac/Transplant ICU, Critical Care.

Woah!!!! We had an issue like that when a pt was coming out of the OR looking like a hot mess. Apparently the Alaris pump was under anesthesia mode. When we were soft coding the patient, the primary nurse was on IV drips, I was on rapid transfuser/pressure bag duty, someone else was on meds, someone else was on supplies, another nurse on the computer, and it wasn't until another nurse on the other end came in and noticed that the fentanyl drip was going wayyyyyy too fast. So the patient got something like 150mL in like a half hour.

Now that I think about it, I find that kind of hard to believe on an Alaris pump because even the fastest setting on an Alaris is 999 mL, therefore it is physically impossible for the pump to go any faster, so 5-10 seconds for 250mL is quite outside the realm of reality. Even if you pressure bag a 500mL bag of any fluid, it definitely takes longer than a minute. Now if you are saying 5-10 seconds for a 250mL in a hyperbolic manner, then okay. Otherwise the rates that you are talking about are even faster than a Belmont or Level 1 Rapid Tranfuser rates....... :sarcastic:

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Specializes in Emergency Medicine.
Yep this wasn't documented but my charge nurse took the pump with the same settings I had programmed and just put a 500ml bag of saline on the pump. Even though it read fentanyl 100mcg/hour it pumped the entire bag of saline out in no time at all...under 1 minute. I should of had this documented but either way the patient ended up fine and I don't work on that unit anymore.

An alaris pump is not able to infuse a 500 ml bag in under a minute. Maybe you are exaggerating a bit. The tubing for those pumps does not allow for a gtt that fast; also, an 18g cath can only infuse approximately 260 ml per minute on a pressure bag- look it up. So you saying a 250 ml bag of fentanyl went in in 5 secs is untrue. Perhaps you meant 5 minutes.

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Specializes in Nsg. Ed, Infusion, Pediatrics, LTC.

This is the 2nd Alaris related infusion problem I've read about today on all nurses. Hope the pumps were locked out/removed and the events reported to Alaris.

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An alaris pump is not able to infuse a 500 ml bag in under a minute. Maybe you are exaggerating a bit. The tubing for those pumps does not allow for a gtt that fast; also, an 18g cath can only infuse approximately 260 ml per minute on a pressure bag- look it up. So you saying a 250 ml bag of fentanyl went in in 5 secs is untrue. Perhaps you meant 5 minutes.

there was no volume given in the OP

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Specializes in Cardiac/Transplant ICU, Critical Care.
there was no volume given in the OP

It is true that there was no mL stated, but the OP said "so I was hanging a new bag, 25000 mcg in total bag."

I believe the OP meant 2,500 mcg just due to the fact that almost every bag of fentanyl in the history of ever is 2,500 mcg in 250mL.

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