mixing pain medications with a flush

vanessaem, BSN, RN · Sep 7, 2018

I dilute narcotics and benzos with 5cc's of NS in a 10cc syringe. When the patient asks me why, I tell them because the drug is very potent and they can potentially go into respiratory failure and that death is a lot worse than pain. :rolleyes:

Guest219794 · Sep 7, 2018

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.

How? How would you hear about it?

Let's say you are ordered Valium, IVP- how, in your facility would you know that it is incompatible?

remotefuse · Sep 7, 2018

This is an old (nurses) wives tale. ISMP has multiple statements on the subject, generally finding that nurse's often unnecessarily dilute medications that do not require dilution, this introduces the opportunity for contamination of the solution as well as potentially serious incidents.
In the case of opiates for instance, there is no purpose to diluting. Pushing 2mg of morphine over 2 minutes isn't any different if that 2mg is in 2ml or 10ml. All you're doing is diluting it outside of the body rather than in the vein, there is no pharmacokinetic difference between the two.

I've thought this as well, but as a pp mentioned, it is much easier to push 10ml over 2 min than it would be 2ml. I have searched for research on best methods, but haven't found anything that says its wrong to dilute for push. If anyone has any sources for this info, please share.

Guest219794 · Sep 7, 2018

This is an interesting thread to me. The topic itself is interesting.

More interesting, to me, are the responses.

One of the most common rationales is essentially, "I do this because it is how I was taught."

That is pretty reasonable for a novice nurse, overwhelmed by just keeping up.

But, at a certain point, we need to take professional responsibility for our decisions, and have evidence based rationales for our decisions. Or, at least written policies backing what we do.

ISMP details an incident in which a nurse caused a death by administering precipitate. Imagine explaining in front of a professional board, or a jury that your rationale for a practice is "well, that is how I was taught."

There are many nursing myths, and questionable practices we are taught- and then teach others. I know I am guilty of this. There are some practices that I take for granted until one day I hear or see something different, and examine my own practice only to find I have been doing something wrong.

Just because the battleaxe that trained you puts shock PTs in Trendelenburg doesn't mean it is right. But that myth along with others are passed along as fact.

Cowboyardee · Sep 7, 2018

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!

And what would be the downside of squirting out a couple CCs of saline first before pulling up, say, a CC of mediation and never moving past the 10cc mark on the syringe? This is the most common technique that I see when pre-dulled flushes are used for dilution.

I mostly see people pulling back past the 10cc mark to "break the seal" before use without squirting saline across the room, rather than to accommodate diluting medications.

JKL33 · Sep 7, 2018

hherrn,

Thank you for the link.

As I'm sure you may also have noticed, this particular ISMP report is chock full of "distractors" with regard to the issue we are discussing. I agree this topic is very interesting; frankly I am becoming beyond curious about what all is behind it.

Speaking of evidence, here ISMP uses heading format to introduce the problem of prefilled saline syringes and then the subsequent paragraphs do not say one.single.thing about them other than that they have coincidentally been used to perform nursing tasks in ways that are directly in complete disregard of basic essential principles that every single nurse living today has been taught.

I'm sorry but honestly statements/position papers/articles written like that reinforce my belief that we are being taken for complete and utter fools a great deal of the time.

Somebody just let me know what this is really about. If the damn vials of diluent have become too expensive, just say so.

JKL33 · Sep 7, 2018

I can't possibly be the only one who thinks that discussing this using examples of nurses who use disposable IV equipment on more than one patient or some nurse who keeps flushing a central line that is occluding due to obvious precipitate is exceedingly disingenuous.

I have my suspicions what all of this is really about.

MunoRN, RN · Sep 7, 2018

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! ]

I've thought this as well, but as a pp mentioned, it is much easier to push 10ml over 2 min than it would be 2ml. I have searched for research on best methods, but haven't found anything that says its wrong to dilute for push. If anyone has any sources for this info, please share.

I'm not sure how it's particularly different since the distance you're having to push the plunger over the 2 minutes is essentially the same whether we're talking 10ml in a 10ml syringe or 2 ml in a 2 or 3ml syringe (you're pushing each one about an inch a minute). If you're trying to slowly push 1ml using a 10ml syringe then I get it, otherwise it wouldn't appear particularly different given the similar plunger lengths.

Guest219794 · Sep 7, 2018

hherrn,
Thank you for the link.
As I'm sure you may also have noticed, this particular ISMP report is chock full of "distractors" with regard to the issue we are discussing. I agree this topic is very interesting; frankly I am becoming beyond curious about what all is behind it.
Speaking of evidence, here ISMP uses heading format to introduce the problem of prefilled saline syringes and then the subsequent paragraphs do not say one.single.thing about them other than that they have coincidentally been used to perform nursing tasks in ways that are directly in complete disregard of basic essential principles that every single nurse living today has been taught.
I'm sorry but honestly statements/position papers/articles written like that reinforce my belief that we are being taken for complete and utter fools a great deal of the time.
Somebody just let me know what this is really about. If the damn vials of diluent have become too expensive, just say so.

I found this when looking for some explanation as to the hazards of using a flush to administer meds. Particularly in light of the fact that my pharmacy directs us to do this with Protonix, which I believe is fairly common practice. I am sometimes in a role modeling position, and even if I believe something to be safe, I want to demonstrate good safe practices.

And the the article cites examples of egregious idiocy, which is best avoided by not being an idiot, rather than creating rules or policies. So, I think we are in agreement here.

My point, or at least the one I was trying to make, was regarding using "that's how I was taught" to justify our actions. That is not how professionals in any field behave.

I know of an instance in which a nurse drew waste off a line, then drew labs. Once done, she gave the blood back to the patient. This was not laziness, it was an extra step for her. She did not try to hide it, she thought she was doing the right thing. OProbably learned it from somebody.

Guest219794 · Sep 7, 2018

I can't possibly be the only one who thinks that discussing this using examples of nurses who use disposable IV equipment on more than one patient or some nurse who keeps flushing a central line that is occluding due to obvious precipitate is exceedingly disingenuous.
I have my suspicions what all of this is really about.

What are your suspicions?

MountainMedicRn · Sep 7, 2018

I always dilute my pain meds...some patients feels the associated nausea pretty quick. I measure it up first to avoid med error.

JKL33 · Sep 7, 2018

I'm not sure how it's particularly different since the distance you're having to push the plunger over the 2 minutes is essentially the same whether we're talking 10ml in a 10ml syringe or 2 ml in a 2 or 3ml syringe (you're pushing each one about an inch a minute). If you're trying to slowly push 1ml using a 10ml syringe then I get it, otherwise it wouldn't appear particularly different given the similar plunger lengths.

It's more about syringe markings than distance. When I was new (establishing practices) there was no need for a 1 ml syringe on my unit, so there weren't any other than insulin syringes, and I had been instructed that those should only ever be used for insulin and given a rationale for such that made sense at the time. So here we were, drawing up small amounts of medication (increments of mls) into either a 3, 5, or 10 ml syringe. I was shown how to dilute for a total of, say, 4 or 8 ml - using appropriate tools and technique. With that, one could precisely deliver uniform aliquots of medication over a desired time - push 1 ml q 30" or 1 ml q 15" and you had your 2 minutes covered nicely without accidentally going too fast or wasting time by going too slow. No one is referring to the distance of anything but rather the use of marked measurements on a given syringe.