Damn near had a heart attack (re: MgSO4)

  1. Why do they even give this stuff anymore?!? :trout:

    Spiked a bag of Mag on a PTL pt (2g/hr=50mL/hr), went to the bathroom, came out to a pump bleeping. I'm thinking "Occlusion Pt side" or something because it's in the AC.

    The other nurse tells me "You ran out of Mag, I took one out of the Pyxis for you" as she's about to spike it (It was bleeping "Air in Line", not "Infusion Complete"). I had nothing to say but "OH MY GOD!" The bag had been hung for no more than 5 minutes!! My heart is racing, my knees feel like they're gonna give out....I'm thinking I just killed this woman.

    Turns out the stupid bag sprung a leak (maybe when I spiked it?) and there was about a 490mL puddle on the floor near the pump.

    Thank God it was nothing serious...But man....It could have been! My knees are still jello-ish and my heart just settled from out of my throat back into my chest.

    Something so potentially dangerous...that has been proven to not be worth the risk as far as effectiveness goes.
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    About KellNY

    Joined: Apr '06; Posts: 738; Likes: 160
    RN
    Specialty: High Risk In Patient OB/GYN

    10 Comments

  3. by   Kyrshamarks
    This hopefully will make you feel better. There has never been a documented case of a pump failure leading to a bag running wide open. The pumps are designed with pistons that when one is open the other is closed to prevent such a failure.
  4. by   tryin4newlife
    omg - talk about a hair raising moment.....Have you recovered yet???
  5. by   Jolie
    OMG! I can feel your shortness of breath over the internet!

    I agree this is a potentially dangerous drug, but as a high-risk mom whose babies would have been born horribly prematurely without it, I am grateful for the doctors and nurses with the expertise to administer it safely.

    Now, take a deep breath!
  6. by   htrn
    Holy Cow!!!!

    I would have had to change my pants....I'm glad things worked out well though.

    {{{hugs}}}
  7. by   jill48
    :stone OMG you scared me. I'm seriously shaking right now. And I don't even give the stuff - I'm an LPN! But still, I'm feeling for you right now because I can just picture your knees like jello. Bad stuff. Too scary.
  8. by   FLOBRN
    I can certainly empathize with your Oh X! moment. In our facility the patient is not to be left alone under any circumstances while the loading dose is being given. In addition in some facilities, the loading dose is in a separate piggyback bag which I think is a great idea. Of course I'm still a fan of the old Buratrols...you only put an hours worth of IV solution in them at a time. Another effective safety measurs.
    FLOBRN
    Last edit by sirI on May 17, '07 : Reason: TOS
  9. by   KellNY
    FLO-Our policy is the same with the load (having an RN there the whole time). My pt was on a 1g or 2g/hr maint. dose. It's always the secondary line.

    lol, hung some mag today, you can bet I scrutenized that thing for any signs of a leak, just to spare myself having to change my undies!
  10. by   SmilingBluEyes
    Breathe.

    And you know why they give this stuff, particularly for PIH/Pre-eclampsia. There is simply no viable alternative in most cases. Lesson learned. I am glad no one was hurt and I feel for you.
  11. by   KellNY
    Quote from SmilingBluEyes
    And you know why they give this stuff, particularly for PIH/Pre-eclampsia. There is simply no viable alternative in most cases. Lesson learned. I am glad no one was hurt and I feel for you.
    For pre-eclampsia is one thing. I completely get that.

    But for PTL...well, studies are really showing that it should not be the 1st choice tocolytic (not I have nothing to link to right now, I'll look at little later--just attended a MoD conference and two of the speakers--MDs--expressed serious frustration with the use of mag for tocolysis). I understand completely the desire to keep baby baking in there as long as possible, but there are better--safer--options out there.
  12. by   SmilingBluEyes
    It's not our first choice where I am. But as you know, there are relatively few things that really successfully treat PTL. But hey, you learned did you not?

    I made a huge mistake with pitocin once long ago on a VBAC/TOLAC person, basically opening up the line (very briefly) by mistake on our way back to a c-section. My heart was in my throat; it was a horrible feeling. Trust me when I say, I never did that again.

    We all need to have opportunities to learn. Thank you for sharing your experiences with us. It's a great way to help others learn from what nearly happened to YOU!

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