Slamming in IVP meds and Running Incompatible Meds Together: Is it as bad as they say

[RNdynamic]

When I graduated from nursing school and worked at my first hospital, I was very diligent about pushing meds at the recommended rate; I remember taking up to 4 to 5 minutes just to push dilaudid, morphine, and demerol. Solumedrol was another one that was pushed slowly. In those days I remember actually holding my watch up to the syringe to make sure I wasn't pushing too much too quickly.

Since that time, I moved to a hospital where no one times themselves as they push meds and since transitioning to critical care, I was told by my colleagues that the "ICU way" is just to push everything fast. I'm not talking about critical situations such as codes either - I am talking about just routine doses of versed for conscious sedation, zofran for nausea, haldol for agitation, fentanyl and pretty much any narcotic too. Everyone just basically slam in the meds then leave the room then continues on their merry way.

Another thing that I see go on a lot is the running of incompatible meds together. We use micromedex which is an online IV compatibility library and what I've found is that a lot of meds that are supposedly incompatible actually do run together. I was always taught that incompatible meds form a precipitate due to acidity or alkalinity of the meds or fluids. However, I have watched nurses set up y-porting 3 or 4 meds that are supposed to be incompatible and they run just fine. Why is that? I even saw one nurse push dilaudid through a line that had TPN & lipids which I thought was incompatible with everything.

Does anyone else witness or participate in these "bad practices?" What do you think of them? I'm still confused on how the incompatible meds run together, personally. Nonetheless, I avoid it.

[jadelpn, LPN, EMT-B]

Yikes!

You can only control your medication practice. I am an LPN who does not push meds, however, have seen that patients seem to have nausea in some instances when a med is pushed too fast. So be sure you do your due dilligence and push at the timing you should.

Do NOT keep everything "status quo" when you are taking over a patient who has incompatible meds running together. Seperate them. It is your butt if the patient has a reaction and "you should have known better". Don't ever get yourself into that foolishness.

You know the correct way. Verify with pharmacy if you have questions. Follow policy. Whatever the others are doing are not your concern.

[Lev, MSN, RN, NP]

I'm interested to hear the input of nurses with more experience than I do. I am personally guilty of pushing meds faster than the recommended rates, but I will not run incompatible meds together or push meds with a line getting TPN. The speed I push meds depends partly on the med (what type of med is this? Is this a new med for the patient? Is the patient getting other meds that can cause similar side effects?) and on the assessment of the patient (size, health status). My "little old lady's" morphine will be pushed slower than the morphine for the huge 250 pound lumberjack, unless the lumberjack is having issues.

In my personal experience:

Protonix and antibiotics pushed too fast can cause burning

Diluadid pushed too fast can cause nausea and light-headedness

When I worked telemetry, I always pushed routine IV blood pressure medications according to their recommended times. I would be very very careful with any IV blood pressure medications, especially with those that also control heart rate.

I am also careful about pushing any steroids. No, I do not push SoluMedrol over 5 minutes, but I will push it slower than Zofran.

IV Zofran is compatible with Dilaudid. :) Dilaudid is compatible with a surprising number of meds.

[Esme12, ASN, BSN, RN]

Well...in reality I don't give every med according to exact guidelines...2-4 mins to push 2mg of dilaudid is ridiculous. Many will not admit to it but they do.

I am careful with certain drugs and different patient. Children I am ALWAYS CAUTIOUS for the margin of error is very small.

There are meds that are compatible by Y-site or manifold. I used micrmedex as well...actually it is a favorite of mine. But unless stated specifically I do not do it. I essentially do NOT give anything in TPN. I have seen certain antibiotics given below the filter after being approved by pharmacy...but IVP meds? no I don't.

It isn't just precipitate but it can cause a decrease of the effect of the med.

Without knowing what the meds are...I can't say for sure...but once again I sit and shake my head wondering...what the heck?

[Esme12, ASN, BSN, RN]

Do I participate in bad practice because others do something or don't do something? NO!

When I moved to New England I was working in an ED and I went to hang Mannitol. I went around asking for a filter they looked at me like I was crazy...."We don't so that here...that is unnecessary" I said really... well then YOU can hang it without one but I won't and preceded to get a filter....when they complained to the medical director about how I delayed this patients treatment looking for an unnecessary filter the medical director had NO IDEA they weren't using one...New policy was posted ALL MANNITOL IS GIVEN WITH A FILTER.

One point me...:)

[MunoRN, RN]

I don't mix meds reported to be incompatible and I haven't found that to be common or even rarely accepted practice. Pushing meds on the other hand does seem to have a discrepancy between actual practice and the ideal/by-the-book way. I usually have some sort of "carrier" line set up into which I put push meds, and then they infuse at the rate of the carrier fluid. This is limited by what else is being carried by that infusion and how pushing a given amount into that line would affect how those other meds infuse into the patient. In the ICU it's certainly not unheard of for nurses to use the CVP line for pushes, which then gets flushed in fairly quickly using a fast flush, I do typically avoid that at least.

[Dranger]

I usually push IV meds pretty fast but I always check IV compatibility along with y-site/stopcock use

[Lev, MSN, RN, NP]

I usually have some sort of "carrier" line set up into which I put push meds, and then they infuse at the rate of the carrier fluid. This is limited by what else is being carried by that infusion and how pushing a given amount into that line would affect how those other meds infuse into the patient.

Describe this carrier line...Do you mean an extra line with just NS running at 5cc/hr? How do you control if the med actually gets to the patient within a decent amount of time if you have a "carrier line" running?

[MunoRN, RN]

Describe this carrier line...Do you mean an extra line with just NS running at 5cc/hr? How do you control if the med actually gets to the patient within a decent amount of time if you have a "carrier line" running?

It's not always an option, but lets say I've got a patient with NS ordered to run at 150ml/hr. I'll separate 50 ml of that out from the 150, and have one line running at 50ml/hr, with another at 100ml/hr. The 100ml/hr line is the one that I bolus from and adjust to CVP, the 50ml/hr line is always at 50ml. I then plug my pressors or other compatible drips into the 50ml/hr line, which allows for more a more timely response from rate titrations, and also avoids having concentrated drips in the line which then results in more significant boluses, lags in rates when you change rates of other meds or push meds. Sometimes I'll even split it into three lines to have a dedicated antibiotic line, and just spot check the CVP.

[Caffeine_IV]

I pace myself when pushing meds but I don't slam it in or watch the clock. I always do a pain med slow if I haven't given it said patient before. Benadryl is one that I push slow. There are others but I can't think of them right now.

[imintrouble, BSN, RN]

I follow the rules in almost all areas of my life.

I think it's a personality disorder, but I really don't want to know.

I always say "Rules keep me safe". I rarely think outside the box, and am extremely boring:nailbiting:

The above is an exaggeration, but not much. You can't say I'm not self aware.

Anyway, I hold my wrist up and watch the seconds tick by while I push IV meds.

If there's primary fluid, I push faster. If it's just a lock, I push slow.

There are variables though. Narcotic naiive = slow. Seeker = fast.

B/P, HR, and resp all get considered.

Compatibility always gets checked. If the book/chart says no, I don't do it.

Ever. Even if that means I take down the piggyback, and hang my own primary tubing. Even if I have to start another line.

[PRNketamine7, BSN, RN]

We have a hospital policy of meds that are compatible with TPN and lipids. I am almost positive dilaudid is compatible with both.