Diluting Meds in Flushes? *poll*

[Summit]

Perhaps some places. When I was a medic students doing clinicals I asked for some flushes and was told a flush was $14 at the hospital. (Maybe that's the billed cost.) But as a result, the flushes were locked in narcotics boxes and nurses caught with them in their pockets were chastised.

$14 for a flush???

That would have to be the billed cost, just like an ambulance service might bill $25 for some tylenol pills that cost $0.02 each.

Seriously... just google this stuff. There are publicly listed prices for flushes at $0.45/flush for a box of 30 or $0.25/syringe for a box of 200 10ml leuer locks syringes.

Now a hospital supply contract is going to get a large price break over that.

And the way a hospital looks at cost is that an extra 10 or 20 cents for flush is more than offset by the saved labor and reduced infection risk of the prefilled flush vs drawing up from saline bags, plus the cost of the saline bags for patients who don't have one spiked.

It is my observation that most healthcare professionals that aren't prescribers (eg us RNs and Paramedics) have no clue what things actually cost or are actually billed for (or actually reimbursed at) in healthcare. It is because we don't typically care about specific costs... yet we are happy to accept and repeat whatever nonsense we are told.

This is similar to the argument I had with someone the other day about the cost of sterile vs nonsterile 2x2s. They were convinced there was some astronomical difference.

 

[hometownmedic5]

I rarely dilute meds in this fashion. If I’m administering narcotic analgesia to a really old or really young person, i will draw it into a flush so I can have a bit more control over the rate of administration, but the rest of the meds I give that I would dilute I’m much more likely to dump them in a 50ml bag and go that route. I routinely have transport times <10 minutes and a high standard to meet as far as accomplishing things en route, so I need my hands to be doing other things.

 

[Tigger]

I rarely dilute meds in this fashion. If I’m administering narcotic analgesia to a really old or really young person, i will draw it into a flush so I can have a bit more control over the rate of administration, but the rest of the meds I give that I would dilute I’m much more likely to dump them in a 50ml bag and go that route. I routinely have transport times <10 minutes and a high standard to meet as far as accomplishing things en route, so I need my hands to be doing other things.

I'll do this or push something into a running line slowly.

 

[NPO]

I'll do this or push something into a running line slowly.

This is what I was taught in paramedic internahip.

In school they teach us to pinch the line and give it slowly. My preceptor's perspective was that, when you do that all you're doing is priming the tubing with your medication, then when you let go of the line and open it back up, it's administered at the rate you have you fluids running.

His pearl was, give it slowly and watch the drip chamber. As long as it's still dripping it's not backing up, and you know how quickly or slowly you're giving the med.

 

[Seirende]

I've had patients ask for Benadryl to be given fast... I won't do it because I know why they want it pushed fast. They usually don't like me too much once they realize they're not going to get it rapid IVP.

I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?

 

[DesertMedic66]

I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?

You can get high if you take enough for push it fast.

 

[NomadicMedic]

Who wants to get high on an anticholinergic? That’s absolutely no fun at all.

 

[Bullets]

I do not know why a patient would want diphenhydramine to be pushed rapidly. My drug book says to give it at 25mg/minute, but it doesn't say why. Would you mind explaining?

It makes you hallucinate

 

[jwk]

One of the things that irritate me greatly right now is that we don't have very many saline vials nor do we have many lidocaine vials. We give a lot of our antibiotics IVP over 3 minutes, preferably diluted in 10 mL sterile water. NS will work in a pinch, but it's less preferable. Why do I bring up lidocaine? Well, ceftriaxone hurts a LOT if not diluted with lidocaine and given IM. I've only given it twice with sterile water in my career so far and that's only because there was no way I could get lidocaine to dilute it with. My patients were warned but even then it's still darned close to torture to give it without lidocaine.

That brings up another issue. I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent. Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility? Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever. I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol). I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.

 

[Carlos Danger]

That brings up another issue. I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent. Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility? Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever. I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol). I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.

Has any harm ever come of the practice?

 

[E tank]

That brings up another issue. I know a fair number of people that add a little lidocaine to propofol (not a great practice for a number of reasons) but not for other medications, and certainly not as a diluent. Our hospital pharmacy nazis would have a fit, and I'll play devil's advocate - is it good practice to dilute any drug with any other drug, IF they haven't been tested for compatibility? Most package inserts will specify what a drug should be diluted or reconstituted with - whether sterile water, saline, D5, or whatever. I'm sure none have been tested with lidocaine (which is why I don't mix it with propofol). I don't have an issue with giving lidocaine before giving a potentially painful drug (although I don't really think it helps much) but mixing them is potentially problematic.

This compatability issue speaks exactly to my post above about pharmacy and nursing using BS as a cudgel to assert some kind of leverage in their worlds. Just got an "incompatable with LR" chart all nice and laminated hung onto my anesthesia machine 2 weeks ago. Know what's incompatible? Rocuronium, cis-atricurium, remi-fentanyl, a bunch of antibiotics that I use regularly and the list goes on. The problem is that the "tests" are about as removed from a full flowing IV line as you can get and don't in the least reflect day to day practice of the use of LR or these drugs. Some OR nurses still get worked up over blood and LR.

 

[jwk]

Has any harm ever come of the practice?

Don't know - like I said, I'm playing devil's advocate. You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns. Yet I see lidocaine and ketamine mixed all the time. I would not use lidocaine to reconstitute powdered meds. I don't think it's good practice, but whether there's any harm in it I just don't know.

 

[NomadicMedic]

Don't know - like I said, I'm playing devil's advocate. You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns. Yet I see lidocaine and ketamine mixed all the time. I would not use lidocaine to reconstitute powdered meds. I don't think it's good practice, but whether there's any harm in it I just don't know.

When I was working in an Urgent Care we used Lido to reconstitute Ceftriaxone all the time.

 

[Akulahawk]

Don't know - like I said, I'm playing devil's advocate. You and I both know that mixing anything with propofol is technically a huge no-no due to infection control concerns. Yet I see lidocaine and ketamine mixed all the time. I would not use lidocaine to reconstitute powdered meds. I don't think it's good practice, but whether there's any harm in it I just don't know.

When I was working in an Urgent Care we used Lido to reconstitute Ceftriaxone all the time.

Whenever possible, I will use 1% lidocaine to reconstitute Ceftriaxone if I'm going to be giving it IM. I will NOT use lidocaine as a diluent for IV administration as 100 mg of lidocaine isn't exactly a small dose and it doesn't hurt to give ceftriaxone by IV.

 

[Brandon O]

These are technically not sterile.

That being said, it's probably about as sterile as many instances of venous access...

 

[E tank]

These are technically not sterile.

That being said, it's probably about as sterile as many instances of venous access...

The NS in the commercially prepared "flush" syringes isn't sterile?

 

[Brandon O]

The NS in the commercially prepared "flush" syringes isn't sterile?

The exterior of the syringe is not sterile. Extruding some of the (sterile) saline and using that space to pull up a medication involves "doubling back" over a portion of the draw, therefore exposing the internal chamber of the syringe to its non-sterile exterior.

 

[Summit]

The exterior of the syringe is not sterile. Extruding some of the (sterile) saline and using that space to pull up a medication involves "doubling back" over a portion of the draw, therefore exposing the internal chamber of the syringe to its non-sterile exterior.

It is no different than drawing up into an empty (internally) sterile syringe wherein the plunger draws across the sterile-but-now-exposed internal barrel.

The portion of the internal barrel of a 10mL (internally sterile) flush that becomes exposed to air when extruding some saline WAS STERILE and becomes no less sterile than in the above and arguably more sterile than a sterile drape exposed to air as when the fluid is redrawn into either syringe, the barrel casing plunger shaft offer protection and so does the double o-ring of the plunger offer a squeegee effect for air deposited material.

It is certainly a contributing rationale to using drawn up meds ASAP.

 

[E tank]

It is no different than drawing up into an empty (internally) sterile syringe wherein the plunger draws across the sterile-but-now-exposed internal barrel.

Well, not really. Nit picking here (REALLY nit picking) but packaged empty sterile syringes are just that. You can dump them onto a sterile surgical field. Pre-filled NS flushes cannot be used for that purpose. That said, there is a big difference between drawing something up with a non-sterile exterior unit and giving it immediately and letting it sit and colonize for a period of time. At the end of the day, as regards the way we are discussing it here, it doesn't matter.

 

[Summit]

Well, not really. Nit picking here (REALLY nit picking) but packaged empty sterile syringes are just that. You can dump them onto a sterile surgical field. Pre-filled NS flushes cannot be used for that purpose. That said, there is a big difference between drawing something up with a non-sterile exterior unit and giving it immediately and letting it sit and colonize for a period of time. At the end of the day, as regards the way we are discussing it here, it doesn't matter.

Yes we agree. I was pointing out that the interior of the pre-filled NS barrel that was covered by the sterile saline but becomes exposed when the plunger is depressed is still as sterile as any other freshly exposed sterile field for the intent of pulling the plunger right back when drawing up.