mixing pain medications with a flush

josbarRN · Sep 15, 2018

In Nursing School, the rule I was taught was to administer IV Morphine 1 mg per minute. I had to deliver a 10 mg dose and my instructor made sure I knew exactly how I was going to administer the dose. Drawing the dose up in a 10 mL syringe allowed me to give 0.5 mL each 30 seconds (do the math). Furthermore, it is important to flush at the same rate that you administered the drug, so I flush with a 10 mL syringe of Normal Saline at 0.5 mL every 30 seconds. I have worked at hospitals where a nurse gave the IV push medication slowly, then slammed the flush in quickly, which made the patient vomit because all the medication in the IV line was then "shotgunned" into the patient's system. And remember that Dilaudid is considered seven times more potent than Morphine, so we should deliver it *at least* 5 minutes per mg. If a patient complains you are pushing the drug too slowly, the patient is savoring the quick intoxicating effect.

JKL33 · Sep 15, 2018

I think the point that has been made fairly well elsewhere in the thread is that the even delivery of aliquots of medication (or delivering a given number of mls evenly over a particular length of time) does not require dilution. For instance, if, for some reason, you really are administering 10 mg of morphine at a time, and if your morphine concentration is 10mg/1ml, there's really no reason this can't be easily accomplished with a 1 ml syringe which would allow you to easily administer 0.1 ml at the intervals you desire.

[i *may have* been won over on this particular point. Still thinking about it. :) However I still don't think that makes dilution wrong at the level of alarm that is being claimed in various places, and I still question whether this is an appropriate method for administration via saline lock or KVO IV, etc.]

josbarRN · Sep 15, 2018

And how many times do you give Dilaudid IV Push to see your patient in a slumber five minutes afterwards?

I hope you will read my response on why it is important to dilute an IV Push Opiate: these drugs *must* be given slowly to reduce the risks of nausea/vomitting, hypotension, bradycardia or bradypnea: think about how you would feel if you drank a glass of wine or liquor over six seconds vs. over six minutes. Alcohol, like these meds is a Sedative-Hypnotic and the same rules apply. When you dilute with a 10 mL syringe of Saline, you are allowing yourself to more accurately administer the dose over the Morphine "One MG per Minute Rule" and Dilaudid is considered five to seven times more potent than Morphine, so it deserves the same if not greater caution when administering IV Push.

Consider that patients on PCA pain therapy receive 0.2 mg of Dilaudid as opposed to 1 mg of Morphine; Dilaudid is at least five times stronger and should be given five times slower than you would give Morphine.

I get frustrated with nurses who shove opiates in quickly: we all have had Pharmacology so we should all know better. Then, because I am doing the right thing, I become the "bad nurse", because the patient asks why I am giving their pain med slower than the other nurses did. If we all adhere to the proper procedures, we are consistent and patients can't nitpick at our methods.

Sorry for ranting. Obviously, no one told you how to properly administer IV push opiate narcotics.

MunoRN, RN · Sep 16, 2018

And how many times do you give Dilaudid IV Push to see your patient in a slumber five minutes afterwards?

I'm not sure what point you're getting to there.

I hope you will read my response on why it is important to dilute an IV Push Opiate: these drugs *must* be given slowly to reduce the risks of nausea/vomitting, hypotension, bradycardia or bradypnea: think about how you would feel if you drank a glass of wine or liquor over six seconds vs. over six minutes. Alcohol, like these meds is a Sedative-Hypnotic and the same rules apply. When you dilute with a 10 mL syringe of Saline, you are allowing yourself to more accurately administer the dose over the Morphine "One MG per Minute Rule" and Dilaudid is considered five to seven times more potent than Morphine, so it deserves the same if not greater caution when administering IV Push.

Why do you consider it necessary to dilute a medication to give it slowly? Whether you're giving a diluted medication in a 10ml syringe or the correct concentration in a smaller syringe, you're pushing the plunger forward and going forward a similar number of graduation marks per amount of time.

Consider that patients on PCA pain therapy receive 0.2 mg of Dilaudid as opposed to 1 mg of Morphine; Dilaudid is at least five times stronger and should be given five times slower than you would give Morphine.

Not sure what you're saying here, are you saying 0.2mg of dilaudid should be given 5 times slower than 1mg of morphine?

I get frustrated with nurses who shove opiates in quickly: we all have had Pharmacology so we should all know better. Then, because I am doing the right thing, I become the "bad nurse", because the patient asks why I am giving their pain med slower than the other nurses did. If we all adhere to the proper procedures, we are consistent and patients can't nitpick at our methods.
Sorry for ranting. Obviously, no one told you how to properly administer IV push opiate narcotics.

The proper way to give IV push opiates is to give the correct dose over the correct time, the volume that does is in doesn't really play into it's pharmacology.

Emergent, RN · Sep 16, 2018

In Nursing School, the rule I was taught was to administer IV Morphine 1 mg per minute. I had to deliver a 10 mg dose and my instructor made sure I knew exactly how I was going to administer the dose. Drawing the dose up in a 10 mL syringe allowed me to give 0.5 mL each 30 seconds (do the math). Furthermore, it is important to flush at the same rate that you administered the drug...

You nursing instructor lives outside of the time/space continuum apparently. She should be mandated to do a breakdown of required tasks, charting, pillow fluffing, figuring in 60 minutes per hour. Don't forget logging on and off the computer and charting to nursing school standards! Everything by the book now, no shortcuts.

josbarRN · Sep 16, 2018

If you draw up a dose of 4mg/mL Morphine in a syringe, you would have to push 0.25 mL per minute in order to follow the one mg/min recommendation. You would have to guess how much that is if your syringe isn't marked to measure out 0.25 mL increments.

If you draw the dose up in a ten mL syringe and have wasted 1 mL of Saline so your total volume is 10 mL, you could then give this medication over four minutes (240 seconds) by pushing 0.5 mL every 12 seconds. Your syringe is marked in such a way as to give this dose accurately. The patient will get the entire 4 mg at a steady rate of 0.2 mg every 12 seconds.

This is why it is important to be able to do math in your head, also. This is too much calculation for some nurses. I am "old school" and we had to be able to figure this out in our heads. This is also why there are math problems on the N-Clex.

Another example: beer bongs. At keg parties, pouring beer into a person through a funnel quickly gets them drunk and vomiting quickly...and this is a PO route. We are putting drugs directly into the circulatory system. Think about it. Please read the earlier post from a nurse who was getting IV push Dilaudid slammed in quickly and how they felt.

We need to take our time and do it right. Every time.

And regarding the comment that my instructor wasn't concerned about time demands: it takes less time to do it right than to have to go back and then give nausea medications or give a reversing agent or call an MD to address the symptoms created because you didn't have enough time to give the drugs properly the first time.

MunoRN, RN · Sep 16, 2018

If you draw up a dose of 4mg/mL Morphine in a syringe, you would have to push 0.25 mL per minute in order to follow the one mg/min recommendation. You would have to guess how much that is if your syringe isn't marked to measure out 0.25 mL increments.
If you draw the dose up in a ten mL syringe and have wasted 1 mL of Saline so your total volume is 10 mL, you could then give this medication over four minutes (240 seconds) by pushing 0.5 mL every 12 seconds. Your syringe is marked in such a way as to give this dose accurately. The patient will get the entire 4 mg at a steady rate of 0.2 mg every 12 seconds.
This is why it is important to be able to do math in your head, also. This is too much calculation for some nurses. I am "old school" and we had to be able to figure this out in our heads. This is also why there are math problems on the N-Clex.
Another example: beer bongs. At keg parties, pouring beer into a person through a funnel quickly gets them drunk and vomiting quickly...and this is a PO route. We are putting drugs directly into the circulatory system. Think about it. Please read the earlier post from a nurse who was getting IV push Dilaudid slammed in quickly and how they felt.
We need to take our time and do it right. Every time.
And regarding the comment that my instructor wasn't concerned about time demands: it takes less time to do it right than to have to go back and then give nausea medications or give a reversing agent or call an MD to address the symptoms created because you didn't have enough time to give the drugs properly the first time.

Even if all you have is 10ml syringes then you've still got graduation marks which are at least every 0.25ml, even 0.2 with some manufacturers. If you have smaller syringes, then you have the ability to measure at 0.25ml or smaller.

While there are avoidable symptoms that occur with excessively fast pushes, there is no evidence or reason to believe that giving an opiate slow enough will negate the potential for nausea or oversedation.

Rainbow_RN, BSN, RN · Sep 16, 2018

I'm a new grad, so I follow what my preceptor does (while still using my best judgment). With that being said, our Dilaudid mostly comes in carpuject vials and our IVs are needleless luer-lock systems. So I usually have to snap the carpuject needle off, and draw it out of the vials using a filter needle. I usually use a 10mL flush to draw and mix with these type of vials bc I have many flushes on hand. It can be inefficient, but I work with what I've got. If I am lucky enough to find the Pyxis stocked with luer lock, prefilled Dilaudid syringes, I push these unmixed and slow. It was interesting to read everybody's input on this, so thank you all.

JKL33 · Sep 16, 2018

Obviously, no one told you how to properly administer IV push opiate narcotics.

Noted.

High road taken.

Guest219794 · Sep 16, 2018

I'm a new grad, so I follow what my preceptor does (while still using my best judgment). With that being said, our Dilaudid mostly comes in carpuject vials and our IVs are needleless luer-lock systems. So I usually have to snap the carpuject needle off, and draw it out of the vials using a filter needle. I usually use a 10mL flush to draw and mix with these type of vials bc I have many flushes on hand. It can be inefficient, but I work with what I've got. If I am lucky enough to find the Pyxis stocked with luer lock, prefilled Dilaudid syringes, I push these unmixed and slow. It was interesting to read everybody's input on this, so thank you all.

Unrelated, but why a filter needle?

Guest219794 · Sep 16, 2018

And how many times do you give Dilaudid IV Push to see your patient in a slumber five minutes afterwards?
I hope you will read my response on why it is important to dilute an IV Push Opiate: these drugs *must* be given slowly to reduce the risks of nausea/vomitting, hypotension, bradycardia or bradypnea: think about how you would feel if you drank a glass of wine or liquor over six seconds vs. over six minutes. Alcohol, like these meds is a Sedative-Hypnotic and the same rules apply. When you dilute with a 10 mL syringe of Saline, you are allowing yourself to more accurately administer the dose over the Morphine "One MG per Minute Rule" and Dilaudid is considered five to seven times more potent than Morphine, so it deserves the same if not greater caution when administering IV Push.
Consider that patients on PCA pain therapy receive 0.2 mg of Dilaudid as opposed to 1 mg of Morphine; Dilaudid is at least five times stronger and should be given five times slower than you would give Morphine.
I get frustrated with nurses who shove opiates in quickly: we all have had Pharmacology so we should all know better. Then, because I am doing the right thing, I become the "bad nurse", because the patient asks why I am giving their pain med slower than the other nurses did. If we all adhere to the proper procedures, we are consistent and patients can't nitpick at our methods.
Sorry for ranting. Obviously, no one told you how to properly administer IV push opiate narcotics.

Regarding your frustration about other nurses not following the 1 mg/min rule:

Like your co-workers, I and everybody I work with apparently also do this wrong, as does every paramedic in this country. I have never seen 10 mg ms given over 10 minutes.

I suspect that, like me, and couple million other nurses, they are unaware of this rule.

Have you got a good reference? I try to base my practice on evidence tempered with experience. Doing something because it is how we were taught is probably the safest practice for a novice nurse, but at a certain point, a nurse needs to practice evidence based nursing.

"Dilaudid is considered five to seven times more potent than Morphine" I am curious about the 1-5 ratio of IV dilaudid/morphine. Haven't seen it before. Could you point me in the right direction on this one? The reference I use put it closer to 1-7, with 1.5 mg hydromorphone IV being equianalgesic to 10 mg morhine IV. So, given the rule, can I give 2 mg dilaudid, over 10 minutes, or should I go the full 14?

"If we all adhere to the proper procedures, we are consistent and patients can't nitpick at our methods."

and

"Obviously, no one told you how to properly administer IV push opiate narcotics"

Are pretty strong and confident statements. It would be great if you could cite sources when you are correcting the practice of other nurses.

turtlesRcool · Sep 16, 2018

Unrelated, but why a filter needle?

Not sure for a carpuject, unless PP means blunt-tip needle, which I know some people prefer rather than using the carpuject attachment to administer the dilaudid.

But about a year ago, our hospital was supplying us with dilaudid in glass ampoules, so we had to use filter needles every time. My favorite was when I went to slide one out of a new box, and a tray of 5 ampules beneath it slid out, crashed and broke on the med room floor. Fortunately, there was another nurse with me who witnessed it, and I know our med rooms are monitored by camera, so there was no question of diversion, but that was a "fun" phone call to pharmacy. Since I can't waste more than I've "taken" for a given patient, I couldn't put an accurate count back into the dispensary computer system, so they had to send a tech to get it sorted. The glass ampoules were only stocked for a month or two, but I was so happy when we went back to regular pre-filled syringes.