mixing pain medications with a flush

Nurses General Nursing

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i was always taught this... mixing my morphine OR dilaudid in a 10 cc flush and push into patient.

a patient asked me, why is that necessary? i couldn't explain.

also, i've gotten orders before to dilute (mix with flush) and to DO NOT dilute (draw and give) form the pharmacy. if i dilute OR NOT dilute the medication, is this a medication error on my part?

Specializes in Critical Care and ED.
had a nurse tell me i need to dilute the 1mg of dilaudid i am pushing into a PICC line, because "it's too close to the heart"...

another 1 told me it will drop the blood pressure alot, if you give it "straight up"

This isn't actually incorrect. A PICC goes centrally so if you instill a crap ton of narcotics centrally and the patient is unstable, you're going to start a whole bunch of hemodynamic instability. This is particularly true on acute cardiac patients and those with sepsis.

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This isn't actually incorrect. A PICC goes centrally so if you instill a crap ton of narcotics centrally and the patient is unstable, you're going to start a whole bunch of hemodynamic instability. This is particularly true on acute cardiac patients and those with sepsis.

Not disagreeing here. Narcotics should absolutely be used cautiously in unstable patients. but maybe you could elaborate.

To my thinking, the vasoactive effects are systemic rather than local. So the question is how rapidly the med is distributed systemically.

While central is fast, so is a decent AC- Think Adenosine.

Two identical patients each getting 2 mg of Dilaudid rapid push. 1 in the AC, one in a PICC. Seems to me that the slight increase in rapid distribution (Maybe a second or 2?)in the PICC wouldn't make a meaningful difference.

Thoughts?

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I don't dilute unless pharmacy specifies to. Depending on the situation, but if the patient has a saline gtt running, I might push half of the dose close to the patient and the other half up higher in the line to or I'll just push it in slowly over several minutes. The way I do it is push half the dose in gently, clean up my supplies, push the remainder in, and then flush. Other times, I will push half the dose in, follow with 5ml flush, push the remaining dose in, and flush again.

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Specializes in Critical Care and ED.
Not disagreeing here. Narcotics should absolutely be used cautiously in unstable patients. but maybe you could elaborate.

To my thinking, the vasoactive effects are systemic rather than local. So the question is how rapidly the med is distributed systemically.

While central is fast, so is a decent AC- Think Adenosine.

Two identical patients each getting 2 mg of Dilaudid rapid push. 1 in the AC, one in a PICC. Seems to me that the slight increase in rapid distribution (Maybe a second or 2?)in the PICC wouldn't make a meaningful difference.

Thoughts?

The bioavailability of centrally-infused morphine is 100%

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Specializes in Infusion Nursing, Home Health Infusion.

If you insist on diluting then please do not even think about using a pre=flll of Normal Saline for FLUSHING to do it.Flushes have an IFU that states they are only to be used for flushing vascular access devices.They are never to be used to dilute IV medications. In fact if you pull back past certain point on the syringe when mixing you can easily contaminate the medication.Only the fluid pathway is sterile unless you are speeding extra money and purchasing sterile ones.It states this on the package.You must dilute with a vial of Normak Saline. THe Institute for Safe Medical Practice also has an advisory out on this too!

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Specializes in Pediatric Critical Care.
This isn't actually incorrect. A PICC goes centrally so if you instill a crap ton of narcotics centrally and the patient is unstable, you're going to start a whole bunch of hemodynamic instability. This is particularly true on acute cardiac patients and those with sepsis.

Not disagreeing here. Narcotics should absolutely be used cautiously in unstable patients. but maybe you could elaborate.

To my thinking, the vasoactive effects are systemic rather than local. So the question is how rapidly the med is distributed systemically.

While central is fast, so is a decent AC- Think Adenosine.

Two identical patients each getting 2 mg of Dilaudid rapid push. 1 in the AC, one in a PICC. Seems to me that the slight increase in rapid distribution (Maybe a second or 2?)in the PICC wouldn't make a meaningful difference.

Thoughts?

The bioavailability of centrally-infused morphine is 100%

Rocknurse, your elaboration is mystifying me far more than your original statement did.

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Specializes in ER.

I think you guys are overanalyzing this.

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Specializes in Trauma, Teaching.

There is no longer a need to dilute, I'm one of those who remember having to draw up morphine from a vial. And didn't that make narc cound interesting! Just where was the line on the bottle?

I have seen people react with getting meds pushed too fast, especially morphine. Instant nausea and puking in some (not all). Also had someone load dilaudid into the morphine drawer and three nurses gave the wrong stuff (READ YOUR LABLE!!). One stopped pushing early as their pt had decreased resps, one had nausea, the third no problems at all. It is the speed you push it, not the volume.

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The bioavailability of centrally-infused morphine is 100%

Still not getting it.

Are you saying there is a difference in bioavailability of medicine given via PICC vs AC?

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It is the speed you push it, not the volume.

It's always been about that. Dilution came into play because it was a means to help better control rate of administration as described earlier in the thread.

Most people push things pretty fast. When I have the occasion of noticing what someone else does, virtually no one is standing there for 2 minutes. Maybe there's something about the psychology of the small volume...."it's just a little bit, won't take long to push." I really can't say I've ever seen someone push 0.2 ml or 0.5 ml or even 1 ml of anything over 2 minutes. Fast pushes of medications do, not infrequently, lead to the things that have already been listed and more....spinning/swirling/dizziness, chest heaviness, feeling of getting pushed down/smothered, "can't breathe," vomiting, tachycardia, transient phlebitis/local irritation, dips in blood pressure (sometimes brief and sometimes not so brief), etc.

[Push fast to keep those dashboard stats looking fine, though! :up: :sour:]

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If you insist on diluting then please do not even think about using a pre=flll of Normal Saline for FLUSHING to do it.

Yes. That is what single-use vials of diluent were/are for.

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Specializes in ED, Cardiac-step down, tele, med surg.

I've usually pulled my antiemetic or narcotic into a 10ml flush. I do this with Ativan too or if I'm pushing insulin. I was taught to do this in nursing school from my clinical instructor who said that it gives a more even push versus a bolus. You wouldn't want to mix something that isn't compatible with NS, but most things are and if they aren't you'll hear about it. It is important to know your compatibility though, if any doubts ask pharmacy.

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