mixing pain medications with a flush

[painmeds]

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?

[That Guy, BSN, RN, EMT-B]

I will dilute my headache cocktails because nothing is worse than going crazy with a burning crotch.

[JKL33]

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.

I can appreciate all of that. I'd say I feel pretty much the same; I don't desire to do things a particular way solely for the reason "that's just how it's done." Just the same, the pattern of change I have seen recently is as follows: Someone or a group wants to change something for their own reasons (including those that are misguided and those that are nefarious), so the issue is talked up and some data is thrown around (which, as evidenced by the the ISMPs statements on this matter, may have absolutely zero to do with the issue in question) and boom - good people are patronized and politely painted as behind-the-times, unthinking/not using evidence, or as being incapable and extraordinarily error-prone, or maybe even just plain purposely reckless or negligent. I'm glad you posted the link you did; I think it can be held up as an excellent example of that which concerns me. (And I do appreciate the tack you were taking when you posted it.)

Several posters here have related our own observations of undesirable patient effects encountered when delivering IV push medications. Admittedly we may be mistaking correlation for causation with regard to the topic of diluting. I haven't run across much writing about these things, yet they are common observations. So, what gives? What gives is that when initiatives are undertaken at all costs and/or outcomes are pre-decided, actual listening by decision-makers appears to plummet.

I suspect this is mostly about the accelerating efforts to eliminate the need for RNs to use critical thinking or to do much decision-making at all. It certainly was not broadcast when prefilled syringes became available that they were NOT to ever be used as many people are now using them. It was emphasized that the syringes themselves could not be placed on sterile fields. My conclusion is that using them to dilute medications originally wasn't an issue that anyone cared about. It has since become one because someone theorized that it should be one. I don't disagree that critical points of patient care should be made clear and uncomplicated, but I am deeply against our professional role being gutted.

[MunoRN, RN]

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.

Smaller syringes use more markings for the same volume, so I'm not sure why it would be significantly more difficult to push slowly using a smaller syringe. 1mg over 2 minutes is 1mg over 2 minutes, whether that 1mg is in 2mls or 10. So if you're trying to go one mark per 15 seconds, for instance, that's the same with either concentration since you're using a smaller syringe for the undiluted injection.

[JKL33]

I found the practice of diluting much more useful in a scenario of higher concentration medications, small volumes to be administered, and saline locks. Particularly all three together as per my original comment on this matter. It's one thing for us to come to a conclusion that past practices may have been unnecessary, but another to claim that they were "wrong" or stupid on the level of "wives' tales," when so many things have changed in the interim.

I remain interested in the issue of reportedly intensified undesirable effects of medications administered by IV push. I suspect this is a result of too-fast administration, but can't definitively say that it doesn't have something to do with concentrations. I really do not think these are urban legends or coincidences or always due to rapid administration. I'd love it if this issue could be addressed by medication safety experts. As there has already been other dismissive commentary put forth on this topic (not by you, Muno), I remain bothered by the whole thing.

[IVRUS, BSN, RN]

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.

If your pre-filled syringe is just in its dust cover, and not a syringe which is sterile (Outer and inner syringe) then pulling back to break the heat seal is a NO-NO. Never pull back, always push forward to break the heat seal from a pre-filled syringe. The only thing sterile in this type of syringe is the NS and only to the end of the plunger.

[IVRUS, BSN, RN]

I was taught to use 10ml syringes for central lines due to high PSI with smaller syringes. Is that no longer current best practice?

I will also dilute for the patient's comfort with peripheral IVs. For example, many people complain of burning when ketoralac is administered straight up, so I'll usually add a few ml to dilute it. With infusions, if a patient can tolerate the extra fluid, I will sometimes y-site meds that frequently cause pain like potassium.

And there are always those doses that are just so small it's impossible to push them slowly; those get diluted, too, unless I have fluids running to push the meds in slowly for me (which I suppose is another way of diluting them).

When initially flushing an IV catheter, one should use a 10cc syringe barrel or larger to ascertain patency... you are correct, but once you realize that the line is open, and that there isn't a resistance to the flow.. USE whatever syringe size you need to administer the medication. SO if you're drawing up 0.125 of Lanoxin to give IVP, do not transfer it into a larger syringe.

[guest940422]

A pt who asks this is looking for a head rush.

UGG they gave me dilaudid when I was in the hospital with a wicked staph infection. Every nurse just slammed it in my IV fast instead of doing a slow push. I don't know if they were slamming the flush or the med was diluted or not (in pain didn't care) but each time i felt like someone punched me in the chest and knocked the air out of my lungs! All I could think about was all the patients who insisted meds don't work unless you slam them. I was begging my nurses to slow down after the first few times. it was terrible.

I only dilute reversal drugs so I can just give enough to wake them up (I only push drugs with carrier fluids so the volume issue isn't a problem)

[Accolay]

I dilute medications if the given dose is a small amount and they are to be given over a specific time period and especially if going straight into an access and not an access with maintenance being infused. If there is a maintenance being infused, I check compatability and will put in a port that's farther away from the pt, then bolus with the pump over the given time period.

I have also diluted 10mEq potassium into a PIV if the pt experiences burning.

The only medication I can think of off the top of my head that calls for dilution is ativan, and then I think it's only to an amount at least equal to the amount of ativan, and that's due to the viscosity of the ativan.

[Accolay]

When initially flushing an IV catheter, one should use a 10cc syringe barrel or larger to ascertain patency... you are correct, but once you realize that the line is open, and that there isn't a resistance to the flow.. USE whatever syringe size you need to administer the medication.

I have some confusion over this. I had an inservice with a company that makes PICC lines and they said that we should not use anything smaller than 10mL syringe to flush a PICC, due to the increased pressure that could dislodge a bit of any fibrin collecting on the end of it. And they definately said not to attempt to push remove a blockage with a small syringe (drawing back is ok.) Had some pretty gnarly pictures of PICC lines with the ends exploded.

Or am I remembering wrong and to only not use smaller than 10mL syringe when there is a blockage? It does make intuative sense that if there is good flow, good blood return to use any syringe you'd like, but if you've not intitally flushed the catheter with a 10mL syringe, then how would you know to draw up your med in something smaller? And does initially mean at the start of your shift or at the start of any medication administration? I stick with 10mL syringes and don't worry about it.

[MunoRN, RN]

I have some confusion over this. I had an inservice with a company that makes PICC lines and they said that we should not use anything smaller than 10mL syringe to flush a PICC, due to the increased pressure that could dislodge a bit of any fibrin collecting on the end of it. And they definately said not to attempt to push remove a blockage with a small syringe (drawing back is ok.) Had some pretty gnarly pictures of PICC lines with the ends exploded.

Or am I remembering wrong and to only not use smaller than 10mL syringe when there is a blockage? It does make intuative sense that if there is good flow, good blood return to use any syringe you'd like, but if you've not intitally flushed the catheter with a 10mL syringe, then how would you know to draw up your med in something smaller? And does initially mean at the start of your shift or at the start of any medication administration? I stick with 10mL syringes and don't worry about it.

A 10ml syringe doesn't prevent excessive pressure in the lumen and doesn't produce less psi than a smaller diameter syringe, all it does it does is produce less psi than a smaller syringe given the same force applied to the plunger, applying more force to a 10ml syringe compared to a smaller syringe will cause more psi to be produced by the 10ml syringe.

So long as the lumen is not occluded, no syringe size will produce excessive pressure in the lumen since the pressure isn't allowed to build up at an excessive rate. Think of it like a balloon where you have cut a big hole in it, how much pressure can accumulate in the balloon with a giant hole in it?

[CharleeFoxtrot, BSN, RN]

...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.

I was actually asked if I re-instilled the waste blood I drew off a PICC line by a brand new nurse I was training. I asked her to think it through as to why that wasn't a good idea, and she had the light bulb moment.

[MunoRN, RN]

I was actually asked if I re-instilled the waste blood I drew off a PICC line by a brand new nurse I was training. I asked her to think it through as to why that wasn't a good idea, and she had the light bulb moment.

It's actually quite common to return the waste to a patient, particularly in settings where VAMPs are used, the belief that blood can never leave a patient and then go back into a patient is more based on voodoo-based-practice than evidence-based-practice.