new med order

SmilingBluEyes · Oct 21, 2005

NEVER EVER had heard of such a thing...

"watch for water intoxication"? INDEED---you are setting this person up for pulmonary edema and massive electrolyte inbalances---- Not to mention, uterine rupture related to prior scar. I hope you did not do this---I hope you involved your manager and the Chief OB.

I would not, could not, do this.

Editorial Team / Admin · Oct 21, 2005

I TOTALLY agree w/Smilin' here. I just completed a med-mal case of Uterine Rupture after high Pit doses. Not at all prudent, IMHO.

RNLaborNurse4U · Oct 21, 2005

today in our unit we have a 24 week fetal demise attempting to deliver. the doctor has ordered high doses of oxtocin for induction. the order reads, " 200 units in 500 ml saline at 50 cc per hour. observe for s/s of h2o intoxication and maternal elec. concentrations..." is this something is totally new or have i been out of the loop. seems scary esp. since she is a prev. c section. stranger thing is, she is barely contraction with this infusion....???

ok, if i'm doing my math equations right........

pitocin - normally given 20 units in 1000 cc fluid, so that the concentration is 1 milliunit per 3 cc/hr. (this is the normal concentration in my unit)

if i have a concentration of 200 units in 500 cc fluid, how many milliunits would be in 50cc/hr?

i'm getting approximately 16.6 milliunits per 50 cc/hr with the original concentration...........and 332 milliunits per 50 cc/hr with the higher concentration.

all i can say is - whoa baby!! no prudent nurse should be giving a concentration that high. that would #1 - rupture her old c/s scar, #2 - oversaturate her oxytocin receptors, making her either be extremely hypertonic, or it would flood the receptors so much that she would not contract at all.

no way would i give this to any patient. no matter what gestation, much less in the presense of a prior uterine surgery. this is just asking for a lawsuit.

to the original poster - what did you do? run the infusion? report this order to your nurse manager and ob head?

jen

Altalorraine · Oct 21, 2005

today in our unit we have a 24 week fetal demise attempting to deliver. the doctor has ordered high doses of oxtocin for induction. the order reads, " 200 units in 500 ml saline at 50 cc per hour. observe for s/s of h2o intoxication and maternal elec. concentrations..." is this something is totally new or have i been out of the loop. seems scary esp. since she is a prev. c section. stranger thing is, she is barely contraction with this infusion....???

that is standard high-dose pitocin protocol for fdiu. we do it at our hospital. i can't find any information about its use in previous c section patients though.

http://64.233.167.104/search?q=cache:zzgxesgyrp4j:www.uams.edu/angels/guidelines%2520finalized/february%25202005%2520fetal%2520demise.doc+high-dose+pitocin+for+fetal+demise&hl=en

altalorraine

RazorbackRN, BSN, RN · Oct 21, 2005

Ok, if I'm doing my math equations right........
Pitocin - normally given 20 units in 1000 cc fluid, so that the concentration is 1 milliunit per 3 cc/hr. (this is the normal concentration in my unit)
If I have a concentration of 200 units in 500 cc fluid, how many milliunits would be in 50cc/hr?
I'm getting approximately 16.6 milliunits per 50 cc/hr with the original concentration...........and 332 milliunits per 50 cc/hr with the higher concentration.
All I can say is - WHOA BABY!! No prudent nurse should be giving a concentration that high. That would #1 - rupture her old c/s scar, #2 - oversaturate her oxytocin receptors, making her either be extremely hypertonic, or it would flood the receptors so much that she would not contract at all.
NO WAY WOULD I GIVE THIS TO ANY PATIENT. No matter what gestation, much less in the presense of a prior uterine surgery. This is just asking for a lawsuit.
To the original poster - what did you do? Run the infusion? Report this order to your nurse manager and OB head?
Jen

Ok, I don't understand how you got that answer...

I understand it to be:

200 units in 500 mls

This would be 0.4 units per ml.

If infused at 50 cc/hr, that would be 20 units every hour that she received.

Am I wrong?

According to my OB book (I am just a student) this is an acceptable rate as long as her previous CS wasn't a vertical incision...

SmilingBluEyes · Oct 21, 2005

What about titration? We titrate pitocin for a reason----esp in cases of prior uterine incision. what if her water breaks? Sometimes when that happens, the circulating prostaglandins and maternal oxytocins rise----then you have a problem if you continue with high doses of pitocin.

So, and starting and maintaining at 20mu/min (or in this case, 33 if I added right) CAN indeed lead to fluid volume overload and electrolyte imbalances. I hope you kept very careful and strict I/O.

SmilingBluEyes · Oct 21, 2005

PS the way I figure it, it would be approx 33 mu/min. THAT is a LOT of pitocin....we stop at 20mu/min and cannot exceed that w/o specific MD orders and a good reason.

But then, my math is not that great....this is partly why we run a standard concentration and at a standard rate. Something like this can cause all kinds of miscalculations, misunderstanding and subsequent problems.

nursey_girl · Oct 21, 2005

All department heads were involved in this decision. This Doc provided literature to back up his plan of care as requested by pharmacy, it was mixed and infused at this steady rate...By me? NO WAY! Luck of the draw or by weaseling my way out... whatever, I kept a low key profile. This patient's husband was an injury lawyer...I kid you not.

End result...This first bag infused with little uterine activity. A second bag was hung around 2AM as agreed to by the patient. Still little uterine activity. At about 8AM she wanted to give up, go home, and try again later as was her option.

One of our nurses has traveled quite a bit and said she has worked in facilities where this was a common practice. I personally was uncomfortable with this practice. This is a new group of docs, some very different approaches, but they have backed up their practices and are highly regarded on our unit and quite rapidly within our community.

My question is, what would have been a safe order. I would think cytotec, but in his literature it states cytotec to be contraindicated with prior C section. The pitocin did not mention it as a contraindication, just provided things to be cautious of...

Altalorraine · Oct 21, 2005

The pitocin did not mention it as a contraindication, just provided things to be cautious of...

Though there may be a danger of uterine rupture with the use of pitocin for prior c section patients, the primary danger with pitocin is to the fetus if the patient has tetanic contractions. That's why we titrate- to monitor how the fetus is tolerating it. If the fetus is dead that problem doesn't exist. With an FDIU if there are tetanic contactions that could result in uterine rupture the pit can be turned off (i.e., rupture doesn't usually happen immediately).

Altalorraine

babyktchr, BSN, RN · Oct 21, 2005

OH MY WORD. Previous csection and high dose pit...would NOT happen at my institution....not no how, not no way. That is quite the pickle, what do we do with demises at early gestations with previous csection and your instituiton has outlawed VBAC delivery?

midwife2b · Oct 22, 2005

There is such a thing as a "high dose pitocin protocol". Several large teaching hospitals investigated it and use it, and our residents use it.

In our hospital it is only used for 2nd trimester demise/placenta detachment.

Our protocol is: 500 cc of NS with 50u of pitocin, run over 3 hr. with one hour rest.

Next bag: 100u of pit in 500 cc of NS, run over 3 hr, one hour rest.

If no response after the one hr rest, notify MD to examine.

SOMETIMES (rarely) we have had to go to 150u of pit in 500 cc, run over 3 hr. with one hour rest.

USUALLY placenta or POC are out during the second bag infusion.

STRICT I&O is necessary. If the patient has any significant medical problem (especially endocrine) she is not a candidate for this type of infusion.

We do apply toco to record contractions, but this is not always done in other hospitals. Again, it is a second trimester procedure and the difference between a second and a third trimester uterus make it an alternative.

I've never seen a problem such as rupture with it, but have had low output and fluid retention from pitocin (in which case it is stopped).