Drips, Slow Pushes

I was watching my preceptee give Zofran the other day and I thought that he gave it a little too fast. I didn’t have the stop watch on him, but I was looking for maybe 30 seconds to a minute for the small 4 mg in 2cc injection, and what I saw was about ten seconds. It wasn’t a rapid adenosine push, but it was more rushed than it should have been.

Now let me confess that I have done the same thing. I have pushed drugs that I know are supposed to be pushed slow maybe a little faster than I should have. In the 911 world time can easily become compressed. 1-2 minutes becomes 10-15 seconds maybe in the same way that for some providers 8-10 ventilations in a minute become 20-30 ventilations.

After the call I cautioned him on pushing the drug slower and when I turned to the protocol page to show him that the drug was supposed to be pushed slowly, I saw in plain black and white that the drug is supposed to be pushed “over 2-5 minutes.”

Surprised by this, I went to the drug insert and read:

“The recommended I.V. dosage of ZOFRAN for adults is 4 mg undiluted administered intravenously in not less than 30 seconds, preferably over 2 to 5 minutes.”

My first reaction, was, well, I can at least go with “Not less than 30 seconds,” but when I discussed the matter with an ED doctor, his reaction was I should do it in 2-5 minutes. Why? I asked. Because it says “preferably” over 2-5 minutes, he answered.

Good point.

Now I suppose if all hell is breaking loose – the patient is vomiting, having a massive MI, I’m by myself, trying to patch to the hospital as well as put in another line, maybe I could get away with 30 seconds. But if I was a regular patient with nausea and vomiting and I read that insert, would I want the drug over 30 seconds? or over 2-5 minutes?

I think 2-5 minutes. It’s hard to argue with black and white.

I love reading drug inserts. You can find all sorts of fascinating information. For example it was a drug insert that confirmed a reader’s tip that Nitrolingual spray can be sprayed on the tongue if you can’t get the patient to lift up his tongue. I read in a drug insert that I had to dilute Ativan at least 1-1 before pushing it IV. And long ago I learned giving Lidocaine to a patient with a bifasicular block will kill them — all things I hadn’t known.

There is all kinds of information in drug inserts — information about drug trials, side effects. Very interesting stuff. My only problem is the print is a little small for my aging eyes.

Anyway, this all has me thinking about drips. When I give Zofran in the future, I will give it by drip. If the patient needs fluid anyway, I’ll just put it in a 250 saline bag and open it up. If they don’t need fluid, I’ll let 200 cc out of the 250 bag and put the Zofran in the remaining 50. (We’re out of 100 cc bags right now).

Back in November 2007, the following article appeared in JEMS:

Is D50 Too Much of a Good Thing?

The point was when faced with a hypoglycemic patient, instead of giving them D50 through an IV and risking tissue necrosis and too rapid an absorption of Dextrose, it would be better for the patient to put the D50 in a 250 cc bag (you would have to let out 50 cc first) and then run the whole bag in as D10. The other good part of this is it makes it much easier to titrate to effect. Some patients won’t need the whole D50. (I can’t find the D50 insert, but an internet site suggested D50 needs to be pushed much slower than I think many people push it — as fast as it will push).

For peripheral vein administration: Injection of the solution should be made slowly. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused ata rate of 0.8 g/kg/hr.

I’ve asked a couple brittle diabetics about their preference between the thick syrupy D50 and the more watery D10 and they have said they would prefer getting the D10 to the D50 which often leaves them with a headache and rubbing their veins.

I’m trying to view things from the patient’s point of view, which I do sometimes, but maybe not as much as I should. I’m also going to try over the next couple weeks to look at all the drugs we carry and find the proper push method and maybe compile a best practices list. While each situation will be somewhat patient/scene driven, I’d like to follow the “preferable” method as much as I can. I just read the Benadryl insert and it says no quicker than 25 mg/min, which would be two minutes for someone getting a 50 mg dose. I’m going to need to slow that one down, too.

***

Update: We had a chemo patient today with nausea. I watched to see how my preceptee would give the Zofran after we had talked about it. He gave it slow IV push over two and a half minutes. It was a fairly straight foward call so after he had put her on the monitor and gotten the IV there wasn’t much else to do. He chatted with the patient as he pushed it slowly. She soon felt better.

8 Comments

  • VA FireMedic says:

    sadly for us, we dont carry zofran yet (we’re still stuck with phenergan). while doing my medic rotations in the ER i came across lots of these situations, where the nurse would ask me “how fast do you push this”, and i would either respond with rapid IVP, over about 30 seconds, or slow IVP. they are much more precise in the ED than we are in the street. very informative post, I will be sure to look into this more!LAM

  • angor animi says:

    We don’t have Zofran in the UK, we use Metoclopramide. I have found that I often do not need to administer this prophylactically before giving morphine IF I adminsiter the morphine nice and slowly. As ever, it is often worth reading the manual / drug insert!

  • Medix311 says:

    You’ve given me a lot to think about. My service also carries zofran and ativan, and as much as I try to adhere to the proper push methods, I fail as often as I succeed. I only wish that my service carried the 250cc bags also.I have been looking for more uses of the 60cc syringe though…

  • DavisEmt says:

    Awesome post. Now to hunt down the drug inserts!We do not carry Ativan, my Med. Director feels it’s used too loosely and has seen too many neg. effects with it. Granted it stinks because most floor docs. want their long transfers getting Ativan if need be…..

  • scope2776 says:

    I was told once in medic school that doing this would be a violation of protocol b/c you’re changing the route of administration from IV push to an IV drip

  • PC says:

    Thanks for the comments.On the protocol question, you should check with your medical direction. Drip or push as long as they get the medicine in a timely and viable form that works for that med, I don’t think they’ll see a problem. For instance, say on a diabetic, all you can get is a 24 in the hand. You can push the D50 into it per protocol or use some common sense and dilute it so it won’t irritate the vein and give it as D25 or D10, which of course will flow much easier. There are some drugs that lose their potency if over diluted — see the Amiodarone insert — others like Dextrose — as long as you don’t over do the dilution and put them into failure, I think you are all right.One interesting thing with the doctors, often when you talk to them about how drugs are given they will admit they don’t know how some of them are given because they just give the nurse the order to give the drug and the nurse pushes it.I think the 60 cc syringe is also a great way to dilute a drug — perfect for giving phenergan. Thanks again for the comments.

  • Witness says:

    Very interesting. What about using a biurette instead of monkeying with bags? The few times I’ve set up drips in my internship I used one, and it worked very well- allowed me to be quite precise.

  • Rogue Medic says:

    PC,A great post.I addressed some of the issues you brought up in my post Not So Rapidly. I include several methods of obtaining package insert materials. There is a lot of material in your post that does not have easy answers. This is some of where EMS mythology begins.I have heard the warning about giving the medication as a drip, instead of as a bolus. Nothing wrong with telling the medical director to change the permitted methods of administration to include drips. It isn’t as if there is a down side with the commonly used drugs for live patients.Medical directors are trying to help you deliver good patient care. Some just are not very good at it.Angor Animi,The need for an antiemetic with opioids is a pretty much a myth – if the opioid is given at the appropriate rate. If you push the metoclopramide fast, it may cause nausea as much as the morphine. Witness,Buretrol/burette use can be very precise, but a lot of services do not carry them and they may cost significantly more than a piggy back drip set (although I do not know the relative costs. I am just guessing).

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