Pushing Versed & Sublimaze

[BinkieRN, BSN, RN]

I took a patient down to the holding area of OR for a quick procedure. The doctor asked me to stay with the patient. An RN was told by the doctor to give 2mg of Versed and 50mcg of Sublimaze. This RN pushed it straight in. The patient appeared to go to sleep quickly but in about 5 minutes she started moving just before the procedure was over. The doctor said give another 50mcg of Sublimaze. I'm not questioning the dosages of the meds but should Versed and Sublimaze be pushed in quickly?

[TazziRN, RN]

Versed is pushed quickly, and I've pushed sublimaze quickly also for conscious sedation. I wouldn't do it if the pt weren't hooked up to monitors.

[GilaRRT]

Some people can develop rigid chest wall syndrome when large doses of fentanyl are given quickly. (Typically seen with induction doses of fentanyl that are given quickly. However, I know of a few reports of chest wall rigidity with smaller doses.

We all know sudden changes in B/P can be related to midazolam. (Hypotension in most cases.) So, I usually give my meds slow IV.

[mandasueRN]

Some people can develop rigid chest wall syndrome when large doses of fentanyl are given quickly. (Typically seen with induction doses of fentanyl that are given quickly. However, I know of a few reports of chest wall rigidity with smaller doses.

We all know sudden changes in B/P can be related to midazolam. (Hypotension in most cases.) So, I usually give my meds slow IV.

:yeahthat::yeahthat:

I actually just did a moderate sedation at work today for a LP and I used

2 mg of Versed and 50 mcg of Fentanyl. I pushed the Versed first, pretty rapid--the pt was rather hypertensive so I was not quite so worried about hypotension. I always give Fentanyl slowly, even though chest wall rigidity is usually seen in much larger doses.

[RN1982]

I'm not gonna push it slow if my patient is out of control agitated.

[Medic/Nurse, BSN, RN]

Good question!!!

I'm not sure what pushing it right in is - but, I'm guessing it took place over seconds not minutes.

I give Adenosine really fast and then there is "everything else" at a slower rate.

Very rarely do I push anything in over 2-3 minutes. However, I do dilute many meds and that keeps the rate a bit slower.

I give Sublimaze doses in the 100-200mcg range frequently for pain indications and in cases of RSI/DAI I will give 250-600mcg as a first dose (along with versed, etomidate and paralytic).

I also tend to give versed meaningfully - when they need it - they usually really need it (seizures, agitation), so...hesitation can be bad. I do give it in increments of 2.5mg per dose and repeat as needed as long as SBP remains above 90.

Sublimaze has a short half life compared with some other analgesics and has less hemodynamic effects - so it is a good choice for procedural sedation.

ALWAYS know the meds you are giving, properly monitor the patient (ECG, Sa02, NIBP, Supplemental oxygen via mask, flowing IV fluids in a good line) and have resuscitation equipment at the bedside (BVM, reversal agents). Remember that the RN caring for these patients should not have any other duties - SAFETY FIRST!!!

I am not ever reckless, but deliberate.

GilaRN is correct about the chest wall rigidity with rapid Sublimaze (Fentanyl) administration - so WATCH OUT! for that as a precaution. I've never had a patient experience that, but I remain aware that it can happen.

With the doses that you outline, and without knowing the size of the patient - it doesn't sound like a problem ... but, I was not there.

Best to ask and afterward ask for a private conversation and use the experience as an educational one for everyone. Heck, the other nurse could be learning from you.

Practice SAFE!

[GilaRRT]

I'm not gonna push it slow if my patient is out of control agitated.

However, the question was in the context of procedural sedation.

[sjt9721, BSN, RN]

ALWAYS know the meds you are giving, properly monitor the patient (ECG, Sa02, NIBP, Supplemental oxygen via mask, flowing IV fluids in a good line) and have resuscitation equipment at the bedside (BVM, reversal agents). Remember that the RN caring for these patients should not have any other duties - SAFETY FIRST!!!

This was my first reaction to the original post. Please tell me the "quick procedure" was performed with the above.

[leslie :-D]

i always push versed slowly, as i do w/any benzo.

fentanyl i push a bit faster yet still cautiously.

according to following link, push both slowly.

Procedural Sedation

http://www.emedicine.com/proc/topic109695.htm

leslie