Multiple doses in same syringe?

[LibraNurse27]

Hi all, I just started working in an outpatient PACU and I already made a mistake =( 7 years as a nurse and the only med error I've ever made was giving 200mg IV thiamine instead of 100mg. I'm used to drawing up only the amount of a med I'm giving and wasting the rest. So if giving 25mcg fentanyl from a 100mcg/2ml syringe, per hospital policy I would just draw up the 0.5ml and waste the rest. Then if I need another 25mcg, do it again. I know it wastes medication but that is how we did it, never walked around with fentanyl in our pockets. 

Here there are orders for fentanyl 25mcg q 5 mins up to 150mcg. Their policy is pull the whole 2ml, give 0.5ml at a time and waste what is left. I feel nervous pushing in only a portion of what's in a syringe, and about holding on to a syringe with narcotic in it. They do have a box you're supposed to lock the syringe in for the 5 mins between doses but no one uses it. I was doing OK when they had 3ml syringes because it was easy to see the markings for 0.5ml, but now they ran out and today I had to use a 5ml syringe with no clear markings other than each 1ml. I wanted to just draw up 0.5 at a time but they said we can't re-access the vial even if clean w/ alcohol pad. I drew up the whole 2ml and when trying to push in 0.5ml accidentally gave almost 1.5! so pt got 75mcg instead of 25mcg. Pt was fine and ended up getting another 25mcg anyway, but I still let the manager know. He was very nice about it, and said it's OK to draw up 0.5 at a time and re-access the vial. He said just don't do it again but don't freak out or beat yourself up. I am so embarrassed to mess up on week 3, but glad pt is OK. What do you think of this protocol and how bad should I be feeling? I usually blow things out of proportion so need perspective!

[klone, MSN, RN]

9 hours ago, TheMoonisMyLantern said:

Nubain, now there's a drug I haven't given in a LONG time. Is there anyone left in our society that's opiate naive enough to even get this drug? 

Some smaller/more rural facilities still use Nubain as IV analgesia in labor, but most have moved to Fentanyl.

I've even heard of a few places that still use Stadol.

[LibraNurse27, BSN, RN]

20 hours ago, MunoRN said:

The 'official' regulatory rule regarding "single-dose / single-use vials is that the "single" part refers to a single procedure, case, or administration.  For instance, the process of recovering from anesthesia is considered a single procedure.  If the medication is ordered as a range and your are starting with the lower end of the range, assessing, and then giving additional dosages within that range then that is considered a single 'administration', and can be done from the same vial.  CMS and state regulators defer to the CDC guidance on repeated accesses of the vial, which it discourages but does not outright prohibit.  Their preferred method is to draw up the amount of medication potentially needed in one access, then give repeat doses from that syringe.  They do say however that the person administering the medication can use their judgement as to whether repeated accesses may outweigh the risks if doing so makes measuring the dose more accurate because you are able to use a smaller syringe.

Thanks! I understand better now. That the way they are doing things is legal and actually recommended but there is a recognition of the risks and allowance of drawing only amount you're giving from the vial. I feel dumb for not being able to only push in the amount ordered from a larger syringe, but it make me so nervous. Either I'll get used to it or just give the dilaudid 0.5mg that comes in a 0.5mg syringe LOL jk I need to do research on which is more effective for post-op pain. I'm guessing start with fentanyl for less severe pain and go straight to dilaudid for more severe pain?

The protocol sort of says that but not very clear, and we are allowed to use our own judgement... also something I'm not used to it! If anyone has opinions I'd love to hear them! The nurse training me said she's found dilaudid causes nausea more often than fentanyl. I gave a lot of dilaudid in the hospital but not much fentanyl.

[LibraNurse27, BSN, RN]

According to my research fentanyl is stronger. I should have known that from just watching the news. And from friends and patients who bought drugs laced with fentanyl or bought street fentanyl... with bad consequences. One pt called it "angel dust" because it feels so good but might for real send you to heaven (as an angel hopefully!). Not good.

also now I found out about Carfentanil which is 10,000 X stronger than morphine and is used to tranquilize elephants! I tiny grain of it barely visible to the eye can get you super high and most likely kill you. and now it's being sold on the streets and other stuff is laced with it... OMG. It says you usually have to get it from a vet somehow, and it comes from overseas, and even vets need a lot of effort to get it, and it has to be stored SUPER securely. fentanyl for elephants... wow. And I don't think any human should ever try it, but I guess too late for that. Now I'm not only stressing about my med error, but about people doing elephant drugs! what a weekend 

[Hoosier_RN, MSN]

1 hour ago, klone said:

Some smaller/more rural facilities still use Nubain as IV analgesia in labor, but most have moved to Fentanyl.

I've even heard of a few places that still use Stadol.

Country Bumpkin General still uses both 

[LibraNurse27, BSN, RN]

Looks like I'll be using dilaudid (not for my own convenience!) but because it lasts longer and less risk for apnea, chest wall rigidity, and addiction. But, onset of action is faster so maybe I'd choose it first for someone in unbearable pain since dilaudid takes about 3 mins for onset of action vs fentanyl less than a min! Dilaudid peak of action says about 8 mins based on studies I'm reading, and fentanyl 2-3. Dilaudid effects can last 1-4 hrs, fentanyl 30-45 mins. So I guess balancing longer lasting relief vs getting people out of PACU faster and letting them start their pain regimen at home? I'm spending too much time on this LOL but then again nothing to do in quarantine, might as well learn... from credible sources of course! Thanks everyone for replies.

 

[Robmoo, ADN, BSN, RN]

On 1/22/2021 at 10:28 PM, LibraNurse27 said:

Hi all, I just started working in an outpatient PACU and I already made a mistake =( 7 years as a nurse and the only med error I've ever made was giving 200mg IV thiamine instead of 100mg. I'm used to drawing up only the amount of a med I'm giving and wasting the rest. So if giving 25mcg fentanyl from a 100mcg/2ml syringe, per hospital policy I would just draw up the 0.5ml and waste the rest. Then if I need another 25mcg, do it again. I know it wastes medication but that is how we did it, never walked around with fentanyl in our pockets. 

Here there are orders for fentanyl 25mcg q 5 mins up to 150mcg. Their policy is pull the whole 2ml, give 0.5ml at a time and waste what is left. I feel nervous pushing in only a portion of what's in a syringe, and about holding on to a syringe with narcotic in it. They do have a box you're supposed to lock the syringe in for the 5 mins between doses but no one uses it. I was doing OK when they had 3ml syringes because it was easy to see the markings for 0.5ml, but now they ran out and today I had to use a 5ml syringe with no clear markings other than each 1ml. I wanted to just draw up 0.5 at a time but they said we can't re-access the vial even if clean w/ alcohol pad. I drew up the whole 2ml and when trying to push in 0.5ml accidentally gave almost 1.5! so pt got 75mcg instead of 25mcg. Pt was fine and ended up getting another 25mcg anyway, but I still let the manager know. He was very nice about it, and said it's OK to draw up 0.5 at a time and re-access the vial. He said just don't do it again but don't freak out or beat yourself up. I am so embarrassed to mess up on week 3, but glad pt is OK. What do you think of this protocol and how bad should I be feeling? I usually blow things out of proportion so need perspective!

Your manager he sounds like a wise experienced nurse.  Most of the PACU environments that I've worked in have operated this way.  

That being said, what do your policies say?  If a major mistake occurs the policies are the standard to which you will be held.  A minor deviation such as multiple draws from the same vial for the same patient are less likely to cause patient harm if you aren't confident about giving multiple doses from the same syringe.  Whenever faced with a problem always in this order ask, "What is in the patient's best interest?  What does the policy say?  What is the standard of practice?"

[LibraNurse27, BSN, RN]

55 minutes ago, Robmoo said:

Your manager he sounds like a wise experienced nurse.  Most of the PACU environments that I've worked in have operated this way.  

That being said, what do your policies say?  If a major mistake occurs the policies are the standard to which you will be held.  A minor deviation such as multiple draws from the same vial for the same patient are less likely to cause patient harm if you aren't confident about giving multiple doses from the same syringe.  Whenever faced with a problem always in this order ask, "What is in the patient's best interest?  What does the policy say?  What is the standard of practice?"

Very good advice! Yes, he is very experienced. I think I will just draw the dose I'm about to give as there is no clear policy, just a preference to do it the other way. At least until I recover from this and feel confident to try the other way again. I'll clean with alcohol pad between each access, and if it's a tiny amount into a big syringe and can't get out all the air, I'll dilute with saline ? thanks!!

[Guest856929]

What about reconstituting it? If it is 100 mcg vials, use a 10 ml syringe and make it 10mcg/ml or use a 5 ml syringe and make it 20mcg/ml. If you do that you'll save yourself the headache of estimating "big dosages" in tiny mls. Of course, you'll have to do some basic calculations, but it is worth it. 

Additionally, it saves you the time to keep re-drawing from the same vial and reduces the risk of contamination. Lastly, label the syringe e.g. fentanyl 10mcg/ml. 

[Guest856929]

On 1/24/2021 at 12:28 PM, LibraNurse27 said:

Thanks! I understand better now. That the way they are doing things is legal and actually recommended but there is a recognition of the risks and allowance of drawing only amount you're giving from the vial. I feel dumb for not being able to only push in the amount ordered from a larger syringe, but it make me so nervous. Either I'll get used to it or just give the dilaudid 0.5mg that comes in a 0.5mg syringe LOL jk I need to do research on which is more effective for post-op pain. I'm guessing start with fentanyl for less severe pain and go straight to dilaudid for more severe pain?

The protocol sort of says that but not very clear, and we are allowed to use our own judgement... also something I'm not used to it! If anyone has opinions I'd love to hear them! The nurse training me said she's found dilaudid causes nausea more often than fentanyl. I gave a lot of dilaudid in the hospital but not much fentanyl.

I'd say dilaudid for long-term pain and fentanyl for short term pain. So if the patient is in sudden sharp pain that is post op, I would break the pain with fentanyl then use dilaudid to mitigate the pain over a longer range of time. 

[Guest856929]

On 1/24/2021 at 12:36 PM, LibraNurse27 said:

also now I found out about Carfentanil which is 10,000 X stronger than morphine and is used to tranquilize elephants! I tiny grain of it barely visible to the eye can get you super high and most likely kill you. and now it's being sold on the streets and other stuff is laced with it... OMG. It says you usually have to get it from a vet somehow, and it comes from overseas, and even vets need a lot of effort to get it, and it has to be stored SUPER securely. fentanyl for elephants... wow. And I don't think any human should ever try it, but I guess too late for that. Now I'm not only stressing about my med error, but about people doing elephant drugs! what a weekend 

Drug dealers are already using carfentanyl to lace heroin. I saw a documentary showing drug dealers in Baltimore using it. They wear gloves and ventilated masks because of how potent it is. Interestingly and paradoxically, the fiends will seek the dealers with the most ODs. Absurdities galore. 

[LibraNurse27, BSN, RN]

11 hours ago, cynical-RN said:

Drug dealers are already using carfentanyl to lace heroin. I saw a documentary showing drug dealers in Baltimore using it. They wear gloves and ventilated masks because of how potent it is. Interestingly and paradoxically, the fiends will seek the dealers with the most ODs. Absurdities galore. 

Wow! That's crazy. and now I want to watch that documentary. 

[speedynurse, ADN, BSN, RN, EMT-P]

LibraNurse - when I was in the ER, we ALWAYS wasted the remaining amount of any controlled substance. We were never allowed to use a vial for multi doses. However, when I went to PACU, it was common practice to use a vial for multi doses. This is something that shocked me after coming from the ER that if a second dose was given from the same vial, that was never allowed to happen again! I don’t know if this is maybe just a PACU thing with using multi dose vials but it definitely confused me with the change of rules coming from the ER to the surgical team!