25000 mcg of fentanyl in 5 sec

Published

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?

Specializes in Emergency Medicine.
there was no volume given in the OP

In my facility, at least two I've practiced in, the volume is 250 ml. Even if it were 100 ml, OP's post still makes no sense and is not possible.

Up Vote Up Vote ×
Specializes in Critical Care.

The maximum rate of the Alaris pump is 999 ml/hr. It would be not possible for the entire bag to be given in the time your post stated. The concentration in Fentanyl is 50mcg/ml. The fact that your patient was ventilated would not have done anything for the resulting blood pressure drop. I find it not believable that the MD was not contacted. The fact that you called the RT who made changes to the vent also is not believable without the MD order. I find your post not consistent with practice.

Up Vote Up Vote ×

Whoa, I use alaris pump, will def be looking at my drip chamber from now on.

Up Vote Up Vote ×

Although the OP may have made an error 2500 mcg vs 25000 mcg, AND the usual volume for a 2500 mcg bag is 250 ml, it is possible to concentrate 2500 mcg in 50 ml.

That being said, Alaris has had multiple recalls for various problems, including too rapid infusion of medication. In some cases, user error was indicated, in others, a replacement part was shown to cause too rapid infusion.

Just as we are taught to "look at the patient" when alarms sound, we must also verify equipment settings and efficacy. Advancing technology does not replace vigilance.

Up Vote Up Vote ×
Specializes in ICU, and IR.

Sorry guys I haven't been on here for a bit let me clear up some things from my original post. It was 2,500 mcg in 250 MLs. The time may have been more than 5-10 secs but I assure you it was not a long time at all. I hadn't left the room yet and was doing a few minor things with the patient like dumping the foley, emptying drains etc. I know the max rate for an alaris is 999 but the malfunction of the pump makes me believe it was infusing faster than that. Trust me I have been doing this for a while and this was way above a normal time. As far as not calling the doctor our RT changed the mode first and then we called the doctor for orders so as not to cause patient harm (I didn't mention this) when a patient needs something urgent you know what to do and you do it then call the doctor for orders, I had a good relationship with these doctors and had worked with them for some time. We may not all do things the same way but I did what I felt was best for the patient in that situation. You can believe my story or not its up to you I was just trying to send out a warning to my fellow ICU nurses...If you chose to ignore it, that is up to you.

Up Vote Up Vote ×
Specializes in Cardiac/Transplant ICU, Critical Care.
Sorry guys I haven't been on here for a bit let me clear up some things from my original post. It was 2,500 mcg in 250 MLs. The time may have been more than 5-10 secs but I assure you it was not a long time at all. I hadn't left the room yet and was doing a few minor things with the patient like dumping the foley, emptying drains etc. I know the max rate for an alaris is 999 but the malfunction of the pump makes me believe it was infusing faster than that. Trust me I have been doing this for a while and this was way above a normal time. As far as not calling the doctor our RT changed the mode first and then we called the doctor for orders so as not to cause patient harm (I didn't mention this) when a patient needs something urgent you know what to do and you do it then call the doctor for orders, I had a good relationship with these doctors and had worked with them for some time. We may not all do things the same way but I did what I felt was best for the patient in that situation. You can believe my story or not its up to you I was just trying to send out a warning to my fellow ICU nurses...If you chose to ignore it, that is up to you.

Did it sound like a jet engine or was there a sonic boom around the brain as the pump was infusing 250mL at a rate of 90,000 mL/hr over the 10 seconds that you claimed it did? Even if it was over one minute, that would be a rate of 15,000 mL/hr. Physics, mathematics, and logic leads me to believe you are over exaggerating by an extremely gratuitous amount. Your statements above, as it stands, is something that I am unable to believe. :no:

Up Vote Up Vote ×
Specializes in CRNA, Finally retired.

I am a CRNA and there have been many situations where I would have LOVED to get 250cc into a patient in 10 seconds. Can't be done - even with a 14 gauge garden hose.

Up Vote Up Vote ×
Specializes in Heme Onc.
In my facility, at least two I've practiced in, the volume is 250 ml. Even if it were 100 ml, OP's post still makes no sense and is not possible.

IT is 100% possible and happened recently at one of our facilities with a bag of heparin. An entire bag of heparin was rapid bloused into a patient....in moments. Difference is Bioengineering was able to replicate the event, and the patient is 100% dead.

Up Vote Up Vote ×
Specializes in ICU, and IR.
Did it sound like a jet engine or was there a sonic boom around the brain as the pump was infusing 250mL at a rate of 90,000 mL/hr over the 10 seconds that you claimed it did? Even if it was over one minute, that would be a rate of 15,000 mL/hr. Physics, mathematics, and logic leads me to believe you are over exaggerating by an extremely gratuitous amount. Your statements above, as it stands, is something that I am unable to believe. :no:

Read my 2nd post I didn't specify a time in that one. It appears there is no need to continue this line of conversation. As I said this was meant to warn others what you do with the information is up to you. some people just have to make mistakes on their own and others have the ability to learn from someones mistakes.

Up Vote Up Vote ×
Specializes in Critical Care.
I am a CRNA and there have been many situations where I would have LOVED to get 250cc into a patient in 10 seconds. Can't be done - even with a 14 gauge garden hose.

Then you've never run a level 1 into a cordis

Up Vote Up Vote ×
Specializes in Cardiac/Transplant ICU, Critical Care.
Then you've never run a level 1 into a cordis

This is true since the Level 1 and the Belmont can max out at about 1,000mL-1,400mL/min and you can only do that if you have a big bore access like the big arm on a Mac Cordis. But for the circumstances in the OP, I am finding it hard to believe.

Up Vote Up Vote ×
+ Join the Discussion