Pushing Dilaudid?

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Hello everyone,

I've worked at two hospitals in my career. The first one where I was precepted I was taught to hang dilaudid in a 50cc bag over 15 minutes to avoid giving the pt a high and perhaps snowing them. At this new place I work they all push it. We have a lot of drug seekers that come in, the nurses push (often high doses) of dilaudid, then I'm their nurse and they complain because I hang it. My take is that they are mad because they aren't getting a rush. I am not comfortable pushing, for example 4mg of dilaudid. In my previous experience when hanging it people got effective more long term relief when I hung it. Now I'm questioning it as I want to give the drug appropriately. It says in the drug book that it can be pushed over 2-5 minutes but it says nothing about hanging it. Just out of curiosity, how do you all give IV narcotics?

Specializes in LTC, Acute care.

At the facility I work, we dilute in 5cc of saline and push over 2-5 minutes. I didn't even know it could be hung and piggy bagged and I haven't seen anyone do it that way so I'm guessing we don't do it that way at this hospital.

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Tha really seems like a step in the right direction the IM does seem to last longer my last surgery (number 6 in a year if it matters) when I went to ER i perfusely vomitting and they pushed 10 of compazine then gave me 5 IM so it would last longer which really impressed me

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To start, I am in the majority and never experienced this slow infusion method, especially for a PRN narcotic order. That doesn't mean though you weren't instructed otherwise. I can see the rationale for this method, but I have to overlook a lot of contradictory information to do so. Like the PDR, most nursing handbooks, even the PI, the drug at nominal dosages is to be given in an appropriate volume over 2-3 minutes (prescribing information) or 2-5 minutes (some nursing manuals). So everyone here already knows that, but why is the slow drip method not the appropriate way, aside from being off-label? A few observations:

1) The patient has been assessed by an MD and determined to be in pain severe enough to warrant the administration of IVP Dilaudid®, so short of a clear error (overdose i.e. 20.0mg mistakenly written where it's clear they meant 2.00mg, etc.), it should be administered as specified. If they are faking symptoms, well what can you do in the face of MD order? I might go a bit slower, perhaps the outer limit of 5 minutes if I was certain or they were a frequent flyer, but it would still be an IVP. BTW: 4-5 minutes is sufficient to provide rapid relief and still keep the rush to a bare minimum. Any longer, such as the method you describe and you risk tissue redistribution mitigating the relief--over 15 minutes it should be a PCA or a long-term continuous dose; that's just pharmacokinetics.

2) Time...wow! Not that I advocate putting a patient in jeopardy for reasons of time, but I also have to be frugal where I can: if that means giving the dose over 2-3 minutes vs. 15 minutes on a piggy back IV, yeah I'd be doing the push.

3) Leaving a narcotic unguarded in an open environment...? Eek! While I haven't experienced such extreme behavior as has been mentioned here, I'm certain addicts lose all sense of judgment when the craving is there or they are withdrawing. That said, I don't think your nursing license would be in danger, perhaps your judgment in that situation, but not your entire ability to practice.

4) Yes, you get a greater likelihood of adverse effects from an IVP, and even large brutes can be taken down by a 2.0mg IVP of Dilaudid®, but the tradeoff is worth it and safe if you are monitoring them. The 15 minute idea may come from the time to onset which is 15 minutes on average. I have seen people get a rush from a 2.0mg dose over 2 minutes, seem fine, and 12-20 minutes later be extremely lethargic, somnolent, and asleep (easily roused by a loud voice or a gentle stimulus--never had to go so far as a sternal rub, knock wood). As anesthesia is my focus, I can say that short of ultra-rapid IVP (measured in seconds=too fast), this disjointed understanding of first clinical effects vs. final clinical effects seems to be the biggest problem. They can have a full-blown rush in seconds and as I said, seem fine, if completely on cloud nine, but the drug is still distributing and the final effect is likely another 10 minutes or more away.

5) If they get a rush, um - I know I haven't contributed to their addiction if indeed they are an addict, but rather I obeyed an MD (or other prescriber's order) and it's on them. If you are mistaken and they aren't an addict or prone to abuse, then you are prolonging the distress, which you're doing if they are abusing opioids as well. This is just my own ethical stand-point, not a decree, just how I feel. I do tell them this: "The physician has ordered an analgesic which is just a fancy term for pain reliever: I will be administering it by inserting into a tube that runs into your vein. Before I do, just to be sure, do you have or have you had any allergies, adverse reactions, or the like to pain medications or any medication? Do you have any questions?" Zip, find the port, establish flow, start the dose. And when you check on them, have a warmed blanket around, they usually will accept it :up:

And lastly as I know it can bother colleagues...even addicts can have pain and the presence of an addictive disorder is not sufficient grounds in and of itself to withhold narcotics.

CNA4Life

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Specializes in NICU, PICU, Transport, L&D, Hospice.

Why are there so many nursing professionals who are poorly informed about opiates?

Why do nurses post questions on AN if they really don't want answers but just want someone to agree with them?

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Specializes in SICU, trauma, neuro.

Push or continuous infusion.

I wouldn't leave any controlled substance unattended and unlocked either.

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We push the narcs where I work unless it's a PCA.

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Specializes in PCCN.

edit- sorry didnt see this was an old thread either

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Specializes in Acute Care.
Our Dilaudid is all IVP, I have actually never seen it given hung.

Same... Been a nurse over 7 years and never even heard of it being hung in a piggyback.

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Specializes in NICU.

I have never seen Dilaudid pushed...we only really push in an emergent situation where we need the drug to act fast...

Dilaudid comes in ampules and we mix it in a minibag and hang it...1-2mg I'll hang in 25ml and anything more I'll hang in 50ml.

That's so strange! I didn't even know pushing Dilaudid was a thing..

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Specializes in Critical Care/Vascular Access.

wow.......bagging Dilaudid? what a new concept to me.

I work on a surgical floor and I would seriously get nothing done if I had to piggyback all the ridiculous amounts of Dilaudid I give out every night along with the plethora of antibiotics, electrolytes, phenergan, etc that has to be piggybacked. I usually just dilute it with 5-10ml of saline and push it slowly (though I don't usually consciously time it).

Interesting.

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Specializes in Critical Care/Vascular Access.

Out of curiosity, those of you who do mix it in a bag instead of pushing it, what kind of unit do you work on?

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Yes of course I leave the room. I don't see how it would be an issue as it is in a bag so the patient isn't going to take it. It's not like a PCA where there's a huge syringe full of narcotic so we have to lock it. Even if they were to take the bag down what would they do with 50cc of fluids mixed with dilaudid? Drink it?

They can empty the bag and share with their friends. Pharmacists will pitch a fit if they find out you're leaving narcotics unsecured.

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