"Must Be Diluted"

NPO

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The phrase "must be diluted" is on many medication vials.
What does this mean? It seems obvious, it must be diluted, but I was never taught this in school. Using the below example, I was taught to draw up the vial, and push it. That's it. Does it need to be diluted in saline first?
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justin1232

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Dude same!!! I was never taught in school exactly what that meant haha 😂 but from what I learned in clinicals and field, you pull up the medication into a flush, or pull up the medication and put in into a 50-100ml bag of NS, or you can pull up normal saline then pull up the medication.
So basically it’s adding the med to saline

But also protocols too. Where I live they say dilute amio when giving for Vfib/Vtac.
We’re i interned they just push it as is.
 

Peak

ED/Prehospital Registered Nurse
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The most definitive answer would be to read the package insert.
 

Summit

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Your protocol should tell you. Also the package insert. Or YOUR pocket drug book. Or your app. RNs usually have micromedex or lexicomp on their computer or phone through their facility as a drug reference.

You can cause adverse effects (or increase the chance of their occurrence) by failing to follow proper administration procedures with some IV meds, such as proper dilution and administration rates.
 

NPO

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Your protocol should tell you. Also the package insert. Or YOUR pocket drug book. Or your app. RNs usually have micromedex or lexicomp on their computer or phone through their facility as a drug reference.
Protocols rarely if ever specify to dilute a medication unless it's intended to be used as a drip. The protocols only say give # of mg because changes in stock or changes in suppliers may change concentrations, etc...

Package inserts aren't carried on the ambulance. Also there is only one insert for maybe 25 vials.

None of those 'solutions' actually seem viable, no offense.
 

Peak

ED/Prehospital Registered Nurse
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Protocols rarely if ever specify to dilute a medication unless it's intended to be used as a drip. The protocols only say give # of mg because changes in stock or changes in suppliers may change concentrations, etc...

Package inserts aren't carried on the ambulance. Also there is only one insert for maybe 25 vials.

None of those 'solutions' actually seem viable, no offense.
You should receive a package insert when you purchase a drug. I think both @Summit and myself recognize that they aren't carried in the ambulance, jump bag, or whatever.

Unfortunately some drugs have different requirements for how and what they can be diluted, reconstituted, or y site administered with depending on the manufacturer as some will use different preservatives or other drug ingredients.

You are responsible to make sure that you are administering the drug in a safe manner.
 

NPO

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We do get the inserts, but by the time one vial of whatever gets to my truck, that insert is long gone. I pull the inserts when I get a chance, but one insert for 25 or 50 vials... It's not like they could send one insert with each vial.
 

VFlutter

Flight Nurse
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For most medications, specifically vesicants, dilution is recommended to prevent injury from extravasation. So giving the medication through a patent IV undiluted likely won't be an issue but does carry an increased risk. During a code situation, just push it. But if you have the time, draw up in a flush. I am sure IVs are infiltrated much more than people recognize.
 
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Summit

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Protocols rarely if ever specify to dilute a medication unless it's intended to be used as a drip. The protocols only say give # of mg because changes in stock or changes in suppliers may change concentrations, etc...

Package inserts aren't carried on the ambulance. Also there is only one insert for maybe 25 vials.

None of those 'solutions' actually seem viable, no offense.
Carrying a pocket reference is not viable?

This one is $8

https://www.amazon.com/Daviss-Pocket-Clinical-Drug-Reference/dp/0803620780/
 

johnrsemt

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In the case of Amiodarone you give 300mg Fast IV Push for Pulseless V-Tach or V-fib in Cardiac arrest. Or 150mg diluted in something over 10 minutes for V-tach with a pulse.
Other Medications vary: Our state protocols say that you give Phenergan mixed in 9mL of NS, in a slow IV push because it is necrotic to skin so if the IV is infiltrated; but you can give it straight if you give it IM; which is a little odd if you think about it: because you would think that IM would be more necrotic.
You can always look up medications online before you get out on the street; because even if you are lucky enough to get the inserts you can't read them in a moving ambulance (The ultimate in fine print).
You can make notes ahead of time and keep them in a notebook or on your phone for when you need them you have a quick cheat sheet.
 

Underoath87

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According to my pharm textbook, an amiodarone push dose is supposed to be diluted in 50ml of NS. But I've never heard of anyone doing this in real life, and certainly not prehospital.
 

StCEMT

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Another area we miss on is what to dilute in. One of our BLS providers was asking about our options for diluting Norepi since the box no longer has D5W and I never actually really knew why it was supposed to be used, just that it was.
 

Underoath87

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According to my pharm textbook, an amiodarone push dose is supposed to be diluted in 50ml of NS. But I've never heard of anyone doing this in real life, and certainly not prehospital.
Went back and checked and it's actually 300mg of amiodarone in 20-30 ml of D5w.
 

Akulahawk

EMT-P/ED RN
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Went back and checked and it's actually 300mg of amiodarone in 20-30 ml of D5w.
It depends entirely upon the situation. In a code, you can just push it undiluted, followed by a NS flush. You can also dilute it in 20-30 mL D5W or NS and administer it as a push. If you're going to run it in as a drip (you're putting it into a bag), you should dilute it in D5W. The literature suggests a concentration <2 mg/mL will minimize vein irritation, if it's through a PIV and that concentrations above that should be given through a central line.

Think of it this way: in a dead patient, phlebitis is not exactly a high priority item of concern. If you get ROSC and Amio is your antiarrythmic, and you've already given it, just start infusing at 1mg/min, record that time you start as 6 hours later they'll want to decrease the infusion to 0.5 mg/min for another 18 hours. If you don't have D5W onboard, just get the patient to the ED soon and let the ED staff know you've given Amio, how much you've given, when you gave each dose, and they'll go from there. If your system expects you to start an Amio drip, follow your protocols for how to create and administer the drip.
 
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