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?
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.
So it's too much to just hang the Flagy alone, but not too much to hang NS (something not even ordered), then piggyback Flagyl? Doubt that one.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
So it's too much to just hang the Flagy alone, but not too much to hang NS (something not even ordered), then piggyback Flagyl? Doubt that one.
You don't need an order to hang NS as a flush for an intermittent infusion (This should get interesting). And you shouldn't hang intermittent antibiotics as a primary without a secondary flush.
You don't need an order to hang NS as a flush for an intermittent infusion (This should get interesting). And you shouldn't hang intermittent antibiotics as a primary without a secondary flush.
I'm not familiar with this, or maybe I'm not understanding what you are saying. For IV antibiotics, you start a NS infusion and piggy back the antibiotic? How come you wouldn't just hang the antibiotic alone and then flush with a 3mL or 10mL NS syringe flush after?
Wrong drug. We are talking about metronidazole (Flagyl), not metoclopramide (Reglan).
You're Sharp!
And we wonder why there are so many med errors! We sometimes have an impossible job: having to be totally focused, while dealing with constant interruptions.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I'm not familiar with this, or maybe I'm not understanding what you are saying. For IV antibiotics, you start a NS infusion and piggy back the antibiotic? How come you wouldn't just hang the antibiotic alone and then flush with a 3mL or 10mL NS syringe flush after?
Assuming you are using a pump, if you hang an intermittent infusion on a primary line and then wait for the pump to alarm when the bag is empty, you leave about 15ml of medication in the line. Many of the antibiotics at my hospital come in 50ml bags, leaving 15ml un-infused would mean that you gave about 2/3 of the dose. This doesn't even count the medication that is wasted when the line is primed (by allowing some medication to drip into a sink or garbage can. By hanging the infusion as a primary/secondary set-up, the secondary can then flush the line of medication, and a back flush can remove any medication left in the drip chamber and the bag, as well as ready the line for another intermittent infusion. You can also use the secondary to prime the line with NS so that no medication is wasted during priming. Our hospital considered making a standing order for this NS bag, but after consulting with our state's nursing commission, we decided that this was a standard of practice and did not require an order.
Perhaps I'm a bit confused but why couldn't the nurse do the following:
+ Stop the fluid (D5 1/2NS 20mEq KCL)
+ Flush the line with a 3 or 10 mL NS pre-filled syringe
+ Run the Flagyl as the primary with its own tubing
+ Flush the line with a 3 or 10 mL NS pre-filled syringe
+ Reconnect and start the D5 1/2NS 20 mEq KCL.
It seems like to me this would make the most sense. You avoid a potential medication reaction and its a fairly simple solution to this problem. Please correct me if I'm wrong.
Specializes in multispecialty ICU, SICU including CV.
Perhaps I'm a bit confused but why couldn't the nurse do the following:
+ Stop the fluid (D5 1/2NS 20mEq KCL)
+ Flush the line with a 3 or 10 mL NS pre-filled syringe
+ Run the Flagyl as the primary with its own tubing
+ Flush the line with a 3 or 10 mL NS pre-filled syringe
+ Reconnect and start the D5 1/2NS 20 mEq KCL.
It seems like to me this would make the most sense. You avoid a potential medication reaction and its a fairly simple solution to this problem. Please correct me if I'm wrong.
!Chris
This is fine in theory IF the MIVF and the Flagyl were incompatible. They are not. You can run it as a piggyback. Check your compatibility resources for yourself. Whoever this pharmacist was in the OP got it wrong.
Another poster mentioned that you need to flush the Flagyl in with another (small) bag of NS, etc. to get the rest of the Flagyl infused. If you are going to hang it on it's own line separate from everything else, you need to do this.
Technically when they write "IVPB", which all IV ATB are suppose to be, they're INTENDING for a compatible fluid to be mainline with the ATB piggybacked into it...
Stop your initial fluid if it's just maintenance fluids (ie- don't stop another drug to hang an ATB), and restart when the ATB is done.
Another alternative to this is starting a new line that would be dedicated so you can have both running. BUT if you have a CHF pt that is fragile, giving an additional 100ml/hr may be detrimental to those patients.
There's really only a few meds that are implicitly NOT compatible with nearly everything. Phenergan, Nexium, MANY ICU meds, etc. are NOT compatible w/ everything but 0.9 (THOUGH SOME ARE ONLY DEXTROSE COMPATIBLE, SOME ONLY LR) Read your manuals.
FWIW almost none of the meds are tested with the 20meq of KCL that's added to a liter bag of fluid. MOST of these compatibilities are tested with the higher concentrated 10meq bags that are infused over an hour (much higher concentration if you think about it ... 10meq in a 50ml bag vs 20meq in a 1000ml bag). I don't think I've heard of any IV ATB's that are NOT compatible with a solution containing 20meq of KCL.
AS ALWAYS if you checked (good for you for doing so, because very few do) and pharm says, "NOPE!" then you HAVE to follow what they said.
FINALLY if you are running something like Zosyn and it's the 4hr transfusion, you're going to need a dedicated line b/c you cannot override the fluids for that long. If it's an hour here and there it's not that big of a deal... if it's 4, you've got issues.
Assuming you are using a pump, if you hang an intermittent infusion on a primary line and then wait for the pump to alarm when the bag is empty, you leave about 15ml of medication in the line. Many of the antibiotics at my hospital come in 50ml bags, leaving 15ml un-infused would mean that you gave about 2/3 of the dose. This doesn't even count the medication that is wasted when the line is primed (by allowing some medication to drip into a sink or garbage can. By hanging the infusion as a primary/secondary set-up, the secondary can then flush the line of medication, and a back flush can remove any medication left in the drip chamber and the bag, as well as ready the line for another intermittent infusion. You can also use the secondary to prime the line with NS so that no medication is wasted during priming. Our hospital considered making a standing order for this NS bag, but after consulting with our state's nursing commission, we decided that this was a standard of practice and did not require an order.
Totally makes sense now. I wonder why this isn't standard practice at all facilities.
katherine100, LPN
310 Posts
So it's too much to just hang the Flagy alone, but not too much to hang NS (something not even ordered), then piggyback Flagyl? Doubt that one.