Pharmacy said no, conventional practice said yes

[anon456, BSN, RN]

I'm a Block 3 nursing student just starting to do IV fluids. Yesterday a patient had fluids running and I had to start a Flagyl piggyback. I had to check compatability of that fluid, D5 1/2NS 20KCL, with the Flagyl. I first looked in the IV drug book and there was no info on that fluids being okay with that drug or not. Then I looked on the hospital med check website and there was no info either. Finally I called pharmacy. After I asked the question, the pharmacist said, "I can tell you it will be fine, but I'll look it up just to verify." After a long time on hold the pharmacist said, "My source said it's not recommended to combine those two because of the potassium is not compatible with Flagyl." The instructor was perplexed and said it was standard practice to run the Flagyl with the fluids, but since the pharmacy said not recommended, we should d/c the fluids and start a new primary line to run the Flagyl, then restart the fluids. The nurse I was working under said that it was okay to run the two together and gave the go ahead and said if I was not comfortable with it, she would do it for me and have it be her responsibility. We went ahead and ran them together.

I felt stuck between a rock and a hard place-- with the pharmacy saying one thing and standard practice being another thing. WWYD? And if there was an adverse reaction, would I be blamed for it for going ahead and running those fluids together, or would it be understood that it was common practice so it was okay that I did it? What should I document if I decided to run them anyway?

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

I would have stopped the primary IV, hung NS, and given the IVPB. But that's just me. Most incompatibilities are based on PH. NS is pretty safe because the patient is 75% NS. Starting another line seems excessive. Just because they regularly give the med that way doesn't make it wise. Blood seems to infuse fine with LR in a trauma setting, but the K in LR lyses the red blood cells in a transfusion. As always, your mileage may vary.

[voraciousj]

I also would have stopped the primary infusion, put up the Flagyl and just switched them back when the Flagyl was done. Better safe than sorry.

[April, RN, BSN, RN]

I wonder what the reasoning was to not hang the 2 together? I know Flagyl is compatible with potassium and D5W. Not sure about the 1/2 NS though... maybe it has something to do with that?

[mauxtav8r]

If pharmacy said no, well, then, no.

[anon456, BSN, RN]

Okay, so can you go through this step by step on what you would have done? Can you hang NS without and order?

[April, RN, BSN, RN]

Okay, so can you go through this step by step on what you would have done? Can you hang NS without and order?

I wouldn't hang NS without an order. Since there was limited IV access, I would have stopped the IV fluids, hung the Flagyl, then restarted the IV fluids when the Flagyl finished. Stopping the IV fluids for that hour or so won't harm the patient, but hanging what pharmacy is saying are incompatible IV meds together might. If the patient has multiple IV meds and this is a continuous problem, a second IV would probably be a good idea.

[Lucky0220]

As a student, right now, you have no license to lose and you were smart to call the pharmacy and defer to your instructor. I feel that any nurse who calls the pharmacy to verify compatibility, and then does not do what they recommended, is taking an unnecessary chance. In this case, the patient's nurse made the call. But when you do get your license, I would definitely encourage you to do what the pharmacist says. Why take the chance....like another poster said, "better safe than sorry.":)

[BittyBabyGrower, MSN, RN]

Always follow hospital policy. If a mistake is made, and you didn't follow guidelines or P/P, the hospital will not back you. With our guidelines, if the 3 sources we use do not have compatibilty listed or unknown, we consider that a no go.

[Lucky0220]

Okay, so can you go through this step by step on what you would have done? Can you hang NS without and order?

This would depend on facility policy. Most will let you override the drug and pull a small bag of NS for a flush. Then you could call or leave a note for the MD to write the order. We do this at my hospital.

[iNurseUK, RN]

Well you learn something new every day!

I had no idea that NS with KCL wasn't compatible with Metrinidazole. I've run these two substances together many times.

I'll be asking our pharmacy about this. Thanks for the heads-up.

[VivaRN]

This wouldn't be as feasible for a nursing student, but as a nurse I try to have some rapport with the pharmacy personnel. Could it be that this is a new pharmacist? Sometimes pharmacy programs flag things that we do all the time.

I would ask a different pharmacist or a pharmacist I trust. I would say, we do this a lot without a problem... can I get a second opinion? And go from there.