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?
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.
Since I don't see a difference between the normal saline that's in a bag and the normal saline that's in a syringe, it's just like flushing. Now some people are going to freak out and insist you get a doctor's order. But there's no difference to me between flushing with a few mls of saline that comes from a syringe and flushing with a few mls of saline that's in a bag.
That said, don't do that if the drug is incompatible with normal saline. :)
I really dont ever run piggybacks as a true piggyback. I almost always withdraw the med out of the big and into a large syringe (relabel) and run it over a syringe pump (flushing line with NS before and after). I just hate the small bags! LOL! Or if I use the bag I just run it by itself (flushing line with NS before and after).
I agree, you dont need an order for a NS flush....sometimes if Im using a lot of flush, Ill draw it up out of a bag into a large syringe (again, labeling it) and use that. It does't matter where the NS comes from, its all the same.
My background is PICU and general peds if that makes any sense. Im also talking about all of those small piggyback bags, not just Flagyl.
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've never heard of needing an order to run a fluid because just to flush a med in (a medline, so to speak). We try and hang most meds with the fluid it's mixed in, so that usually means having a D5 line and a NS line going. All of our fluids are kept in a supply room where you don't need an order to get them. I'm not saying other place's policies don't differ, I just can't imagine obtaining an order for a med 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?
Our IV tubing holds 22 ml. Our Flagyl typically is 100ml. If you're not flushing that tubing after running it primary, your patient is missing almost a quarter of their dose.
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.
I'm sorry for going a bit off topic, but you run Zosyn over 4 hours? We do it over 30 minutes. What dose do you give over 4 hours?
Thank you all for this post, I am a new nursing student and just reading over all of this advice and wisdom is helping me for future clinicals,so what I am gathering is to make sure you comply with the policy of your job??? So this wont affect my insurance at all or my license??? Thank you so much for the wisdom!!!
Our IV tubing holds 22 ml. Our Flagyl typically is 100ml. If you're not flushing that tubing after running it primary, your patient is missing almost a quarter of their dose.
This makes sense since your tubing holds that much. Our tubing holds 10mL and we typically reuse tubing for 96 hours so only the first dose would be missing those 10mLs since the line is already primed with the antibiotic for the following doses.
Looked this up on my lunch break and my online drug guide at work (Micromedex 2.0) says that metronidazole in a 5mg/ml concentration and potassium in a 10mEq/100ml concentration (a lot more concentrated than 20mEq/L) is compatible. I don't know where your pharmacist is getting his/her information.
We always run piggyback antibiotics with IVF that has KCl in it. The bolus of KCL that you would get is tiny -- whatever most of the volume of tubing is -- 10cc at most, and it's not a fast flush (probably 100-200cc/hour at most if you are running flagyl. I believe it is generally over 1 hour.) I don't think there is any risk of cardiac arrest to the patient at all.
I also looked on Micromedex with my instructor and we were not able to find any info. It just said "no information" or something like that. Were you looking under IV compatabilities? Maybe there is another section? In any case we did call pharm and they said not recommended so I agree we should not do that.
As far as morphine push, we were taught 5 minutes and to dilute it to 5 or 10 mL to make it easy to watch the clock and push. Also, never flush the tubing fast after pushing a slow-push drug. You must push it at the same speed as the IV push or you may be giving a fast bolus of the drug without meaning to.
Specializes in multispecialty ICU, SICU including CV.
I also looked on Micromedex with my instructor and we were not able to find any info. It just said "no information" or something like that. Were you looking under IV compatabilities? Maybe there is another section? In any case we did call pharm and they said not recommended so I agree we should not do that.
As far as morphine push, we were taught 5 minutes and to dilute it to 5 or 10 mL to make it easy to watch the clock and push. Also, never flush the tubing fast after pushing a slow-push drug. You must push it at the same speed as the IV push or you may be giving a fast bolus of the drug without meaning to.
Micromedex 2.0 has a specific tab called Trissel's IV compatibilities. You need to go there. I typed in "metronidazole" and "potassium chloride" and got 5-6 hits for different concentrations. None of them said there were incompatibility issues. I am thinking that you didn't search correctly or something (Did you put in the IVF as a search item? That doesn't work.)
Just gotta throw my 2 cents in..we use "Intravenous Medications" as our go to source for compatibilities on the floor and it states "Administer separately, discontinue primary IV during administration, and do not introduce additives into the solution" which might be something that your pharmacist read also (this is the book our pharmacist buys for us to use) so, I don't run Flagyl in anything containing K+, I'll usually PB into a small bag of NS..Some of the other nurses hang it as a primary but I agree with a previous poster about the leftovers in the line. Above all, go with what the pharmacist says, after all, they know waaay more about meds than we ever will, and document that you asked for clarification.
We always run piggyback antibiotics with IVF that has KCl in it. The bolus of KCL that you would get is tiny -- whatever most of the volume of tubing is -- 10cc at most, and it's not a fast flush (probably 100-200cc/hour at most if you are running flagyl. I believe it is generally over 1 hour.) I don't think there is any risk of cardiac arrest to the patient at all.
I just want to be clear that when I discussed cardiac arrest/potassium/bolusing, I was not referring to the heavily diluted 20meq of K in a liter bag, but an undiluted version. As a practice, however, we never bolus patients with fluid containing ANY K. If someone has 0.9 with 20meq K in it and needs a bolus for volume, we always hang a bag without K for the bolusing.
wooh, BSN, RN
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Since I don't see a difference between the normal saline that's in a bag and the normal saline that's in a syringe, it's just like flushing. Now some people are going to freak out and insist you get a doctor's order. But there's no difference to me between flushing with a few mls of saline that comes from a syringe and flushing with a few mls of saline that's in a bag.
That said, don't do that if the drug is incompatible with normal saline. :)