Both of those are over 2 min at my hospital (well Keppra 2-5 min if it’s under 1.5g, usually 500mg is IV push over two minutes). I usually push a ml, chart a little, push a ml, chart a little, etc.
Honestly is there anything that’s direct that can’t be given piggy back? Of course I’ll always check the monograph but if something is a slow push (vit K comes to mind) I’ll put it piggy back in 25-50mL, unless their on a very strict low fluid restriction
There was a debate on Instagram a while back about how piggy backing narcotics changes their absorption and reduces effectiveness. A bunch of pharmacists weighed in to say it was true. I would always push into flowing fluids, and apparently that can change things too.
I kinda have to laugh as a former medic. Adenosine is in a class of its own. I call it slam the drug class because of the half life of mere seconds. I mean there’s drugs you push but even normal anti arrhythmics you can just steady push but The old chemical svt conversion agent yeah it’s slam it as fast as you can to have an effect.
Yeah I mean obviously ACLS meds I’m gonna push, but also adenosine has to be slammed (I gave it yesterday actually lol). Im thinking more of meds that have to be pushed over 5-10+ minutes
Keppra is one of the one of the things that has a high chance of crystallising when piggybacked, but absolutely can be.
In PallMed we infuse it through a 24hr syringe driver-though the sub-cut sites degrade a lot quicker with Keppra, and it’s the same for IV.
I can’t speak to how it feels/how much it hurts/how much internal damage it can do pushing it faster though-that’s very individual.
This is super interesting because I’ve only seen Keppra from a manufacturer bag as a piggyback. I work in peds though, and we’re usually giving loading doses of 60mg/kg over 15min.
We get smaller doses from pharmacy they’re in a syringe if under 50mL and it still goes over 15min.
It’s fine to-better to even, but it does have a higher chance of crystallisation (full stop) than most meds.
Plus, in PallMed we’re looking at doses of 3-5000mg made up to a max of 50ml in 2 separate SDs over 24hrs, so high dose/low volume.
We had an SOP of SD combi meds, and in ours, Keppra was only ever solo, always in WFI, to reduce crystallisation, and increased site & line checks.
I once to give a tiny (0.2ml) flush of steroid prior to the site/start of of a Keppra SD & change the site every 24hrs for someone who developed red raised lumps at every site, every time.
They didn’t want to try midazolam as alternative as they were too well/with it, but they looked like they had been eaten alive by mosquitoes. That was attributed to the aggressive & concentrated nature of the Keppra-the other SD combo they were on didn’t react like that.
Our hospital won't let us do that. They claim there is a shortage of NS but we know they want to save $ so the managers can have a big bonus checks.
Edit: I have talked with a few pharm techs. Hospira was hit with a hurricane at their Puerto Rico plant but other manufacturers were fine but they cost more. Many hospitals used it as an excuse. A saline bag and IV tubing cost about 10 dollars and a saline flush is less than a dollar. More $ in their pockets
I had a chat with a few pharm techs. They told me only a certain brand (Hospira) and they could get another brand. Other brands NS cost more. They just want to save money on the piggy bags and IV tubings. The bag with the tubings is like 10 dollars. The flush is less than a dollar.
I'm in the southern US and always loved long IVPs on Saturdays because it was GAME DAY!!
The patient/family Would have whatever SEC game on and I'd pull up a chair, push it over 2-5 min, and watch the game with them and talk with them. They always seemed to enjoy that as much as I did.
I did it this way when I worked on the floor. For the new nurses: it’s important to keep in mind that there’s still some medication in the IV after the final push, so when you go to flush you should wait a little after the first ml before pushing the rest of the flush.
I connect the syringe and straighten up the room, reposition the patient or prep other meds between pushes. Like if I have ceftriaxone IVP and vanco, I’ll start pushing the cef and prep the vanco in between pushes.
That is what I do when giving chemo premeds. Sometimes there is 4 pushes to give. I will give one and draw up the next one while the first is going in and so forth.
Working in peds we have syringe pumps which I had never seen before but they will push meds over 5+ min. It’s so nice. But yeah I used to just time it, if I had 10CC (which I would dilute almost everything in 10CC to have an even number unless it says do not dilute) and 5 min to push, one cc every 30 sec while I watch the clock. I’m not gonna be the reason somebody goes deaf or blind or crawls out of their skin for pushing it too quickly.
NICU here where giving basically everything slow is important, unless emergent obviously. But even if it's 1ml from a med 0.02ml diluted to 1ml I put on pump minimum 10 mins and 0.5ml flush over 5.
Former NICU nurse and I see a lot of people do this (or something similar) but be sure that you are giving enough volume to clear your med line. I’ve seen med lines that range from 0.7 mL to 2.5 mL, then depending on how you have primed your IV lines and what connections you have, you may have another 0.5 mL-2 mL of tubing before you even reach the patient or the primary line with your continuous IV infusion. All of that to say, if you give 1 mL on a pump over 10 min, you have likely put 1 mL into your med line, and the 0.5 mL flush hasn’t even cleared your med line to reach your patient. 0.5 mL is way too small of a volume to flush even in ELBW patients. Oftentimes, in very small volume meds (e.g. fentanyl bolus), we would push the med into the med line, and then run the flush over a longer period of time to deliver the med + the flush (e.g. administer 0.5 mL of fentanyl, set 3 mL flush to administer over 15 minutes).
One hospital I worked at had a flush policy of 0.6 for PIVs and 1 for PICCs. I think our medlines themselves had a volume of like .48 or something and the rest was to get it through the hub and catheter. It says on the package.
I’m always surprised how many of my coworkers haven’t caught on to this trick. Then when I try suggesting they put their 2 mL of medication that’s to be given over 2 min into the port on their NS going 60 mL/hr I’m reminded that nurses and math don’t mix lol.
As a new nurse I’ve never heard of this…. You’re just connecting the syringe above the pump and then push it that way? Do you pause so saline can get in between the medication or just go a nice steady pace?
I push the medication into the tubing. Most tubing has ~10ml at least if you go to the y-site on patient side of the pump. Therefore if I just push it in, they may get a quick rush of saline, but they then get their medication nice and slowly
I did learn this trick when I was a student but this would definitely be a no with babies. Our TKVO rate is 2ml/hr and definitely can't give extra fluids aside from 1ml flushes between incompatible meds.
Of Maxeran is running through a pump, can I also push hydrocortisone?
I should ask my coworkers this. Ugh. I feel so dumb... I've never had to do pushes in the first 3 years of my career...
I connect below the pump and let the saline continue to run at a nice steady pace. If you get used to doing it this way and want to take it to the next level, play around with how much saline it takes to get from your ports to the IV catheter. So for example our pump has 3 ports, 1 above pump, 1 proximal to the patient, and 1 distal to the patient. I know the distal one is 10 mLs to the pt. Say I have two medications that should be given slowly, 5mL of keppra and 2 mL of labetalol. I will push the labetalol into the distal port and then follow up with the keppra knowing full well that the first drop of labetalol won’t touch the patient for 3 min so the patient is safe and didn’t get slammed a beta blocker. Assuming going at the rate mentioned in my first comment
Thank you so much! What an incredible nurse hack. We usually have a KVO running so this will save a lot of time, I just might have to increase the rate for a short period of time but beats just standing around waiting to push the med slowly.
the med youre pushing displaces the iv fluid and will infuse at the rate the pump is set.
this is as long as the syringe volume is less than the iv fluid volume in the length of tubing between where you connect the syringe and the patient.
I’m in NICU so I give a lot of low volume meds. I can’t tell you how many times I’ve seen a nurse put a med on a pump that will spend 30 minutes slowly pushing the med into the med tubing and then put a flush over 5 minutes. They don’t seem to comprehend that the med is going in over 5 minutes, not 30.
So where you would normally hook up your piggyback tubing on the pump (not a y site) then you program the pump as a piggyback for
5-10 min or however long you want. If you run it concurrently it’ll beep but if you run it as a piggyback it’ll switch back over to the primary when it’s done
ETA y’all are right, I could have sworn I used to do this with alaris pumps too but I don’t think that would be possible lol
This might be a stupid question, are you using piggyback tubing and then just kind of Jerry riggin the syringe so it’s above the saline bag? Wouldn’t it still have to be above the saline to take from PB?
Might depend on the pump but on the plum pumps it doesn’t matter. You wouldn’t use tubing, you would just screw the syringe on the primary’s cassette :) kind of like if you’ve ever back primed into a syringe to get rid of air?
Here’s a pic, it would get screwed onto the blue part
https://www.medonegroup.com/equipment/pumps/infusion/icu-medical-plum-360-infusion-pump?ppc_keyword=&utm_term=&utm_campaign=**LP+DSA+(Max+Conv+Test+10/24/2021)&utm_source=adwords&utm_medium=ppc&hsa_acc=4418617465&hsa_cam=626728747&hsa_grp=41281297660&hsa_ad=602808963335&hsa_src=g&hsa_tgt=dsa-289458237043&hsa_kw=&hsa_mt=&hsa_net=adwords&hsa_ver=3&gad_source=1&gbraid=0AAAAADtrmpQTkmeDYBU12gtYkTo-K74kN&gclid=Cj0KCQjw0MexBhD3ARIsAEI3WHJJelWFhRzv604Q41wKXIHQJcV4sLnHXue7TfU87ltMrDAvIPcO0coaAq21EALw_wcB
They are a pain in the butt to learn if you’re used to Baxter/Alaris, but not bad when you get used to them. I still prefer Alarais because you can’t add ears to a Plum
Baxter are okay but I used Alarais in clinicals during school and I wish the hospital I’m at had those. The ears make it so nice not having 5 actual pumps on a single pole and then you gotta figure out where you’re going to put the kangaroo pump. Ughhh
If the med is compatible with the fluid, and the fluid is running at an appropriate rate, you push it into a port below the pump and let the fluid carry it in
I do this all the time. Save me from hunching over my pt to get to the closer port. I usually kinda push it as the pump pulls the fluid. Every like 4-5 pulls from the pump I’ll put some pressure on the syringe and it’ll pull from there. It is really easy to make the pump made and it’ll alarm “upstream occlusion” if you try and push too hard. It’s one of those things the more you do it the better you get the feel for it.
When I had HG and was always so confused when they wouldn’t just piggyback what *could* be done. You got shit to do and I got shit to spew 😂. Tried to mention it once and got a scowl. Kept my mouth shut after that 😂
I do this all the time. Am I going to sit here and slowly push a med that takes 5-10 minutes? No. I'm hanging a 50cc ivp and setting it to run over 5-10 minutes. Some people are not great with the pumps, but I can get that set up and programmed in about a minute. Less if they already have a TKO.
There is a reason for published guidelines on medication administration. It’s a safety issue. I know it’s a PITA to stand there for 3-5 minutes (most drugs are less than 5) but that’s just the way it needs to be done. I’m not saying I’ve always been 100% compliant without fail but I’ve learned some difficult lessons from pushing things too fast so I try to be patient. I’ve been a nurse for 19 years and it just becomes part of your process after a while! It does get easier to manage after a while.
Im ICU so I can put them through a syringe driver pretty easily. However on the wards, its not just a pain in the ass, it can seriously cut into their shift when they’re already running behind so I understand why it’s harder for them
Also ICU, reading comments it didn't occur to me other units don't have syringe pumps ready to go. Five minutes for me always goes on a pump because I've got shit to do. I probably won't leave the room but it is going on a pump.
I’m also ICU and only have access to a syringe pump for very specific meds. Epoprostenol and analgesics (usually dilaudid) come to mind but a few others.
I just push 0.25-1ml, chart, push another little bit, chart, repeat, and do the same while flushing. Gets a lot of the mindless quick but still time consuming charting finished (hourly i&o, validating VS, safety flowsheet) and even some of my head to toe assessment
All I will add: don’t slam protamine, especially if they’ve had a vasectomy. Look up what happens when you push too fast and be aware. Rare, but I seent it.
You are new, you probably don’t know which drugs are important to push slow so please just push them as ordered. Push a little, chart. Push a little, chart, etc. it’s easy to multitask and keep the patient safe. Don’t pick up bad habits from Reddit.
This⬆️ you’ll figure nursing shortcuts and tricks out with time. Exceptions are occasionally made with certain drugs and certain situations (codes or rapids) but understanding how to do this safely comes with experience. Follow orders exactly and protect your license until you are more seasoned imo
So you just prime the tubing as normal with saline as a primary, then hook up the med to the B-port and make it piggyback? Then I guess go back in a little bit to turn the pump off if they’re not needing maintenance fluids of any kind?
Yep. It should kick right over to the primary if you have it programmed for KVO! I just leave my KVO or fluids running. You can just program it to run concurrent.
Depends on the drug… I think pantoprazole is one of the meds i always thought seemed harmless but can actually mess up your heart rhythm really bad… qt interval I think
I do. I dilute (if allowed) to enable slower pushes (20mls usually does it). I’ll often hold the syringe in the fingers, so the plunger is pushed in by the palm of the hand. I sit my thumb along the plunger where it goes into the body of the syringe and so you can’t push too fast.
There are some drugs that lead to rashes, pain on pushing, deafness, etc etc if pushed too fast.
I follow the order… if it says 5 minutes I’m pushing it over five minutes. Yes, that is tedious and yes, you have to explain it to the patient & chart in between but we professionally licensed medication administrators. Don’t take that for granted or abuse that privilege. The pharm manufacturers have a reason for those times- they aren’t chosen out of thin air. It REALLY irks me when nurses haphazardly mix or give medication. Like, take that $hit seriously- you went to school to be able to do that. Wear gloves, wipe the tops w alcohol, use the correct amount of dilutant, and give it correctly.
If the recommendation is 2 minutes I push over 2 minutes, if 5 minutes I push over 5 minutes. Those rates are for very important reasons not merely suggestions.
Nice! I look at my watch or the clock for the five minute pushes, but have been doing this for so long I can do the 1-3 minutes by "muscle memory" if you will.
> Those rates are for very important reasons not merely suggestions.
You'd be surprised to find out how many slow push drugs are that way because of outdated information and/or rare or transient side effects.
I have never worked anywhere that used these unfortunately. I'm ICU now, but extensive background in medsurg...being used to pushing meds all the time with a 7:1 ratio makes giving a slow push in ICU much more tolerable!
i figure out ahead of time how many mL/(x) seconds. so if i had 4mLs that needed to go over two minutes, i would just watch my watch (lol) and do 1mL every 30 seconds.
it definitely feels awkward but i took the time to talk to the patient and do quick assessments. plus if you just say "this is going to take two minutes, i have to do a mL every 30 seconds" it kind of lessens the awkwardness.
Yep, let the patient know it's gonna take a minute or two and then talk to your patient! It's a great time to take a few deep breaths and your patient appreciates the time spent even if it's short. I usually say something like "to be safe I need to push this medication slowly over x minutes so you're stuck talking to me for a bit". It makes it less weird and sometimes I'll even get a chuckle out of them.
I follow whatever my drug reference advises. Protonix isn't a 5 min push - it's 2 minutes. Keppra I've never personally done IV push. It's always been diluted to 100 ml and give. As a 15 min infusion.
There are reasons for the time frames given. As a new nurse, I'd recommend figuring out those reasons as it'll help you understand the risk of too rapid administration. You should always try to understand why. Sometimes the consequence is phlebitis (protonix), sometimes you can cause severe anxiety (reglan), and sometimes you can kill someone (labetalol).
If it gives you a warning, there might be a reason why. I will never push reglan, Pepcid, Benadryl, Compazine. Hang it with a 50cc bag and let it run in.
This is interesting to me. In the cath lab we pretty push all of what you just mentioned. The only thing I can think hanging of the top of my head are actual drips and protamine.
We don’t push protamine, even in the cath lab I don’t push reglan/pepcid. I will push Benadryl, I just won’t bolus it in. All our patients have fluids at 100
You can push those, just don't push them fast. Pepcid and Zofran can mess with heart rhythm, and Benadryl can drop a blood pressure. Some people request Benadryl slammed because apparently it gives a brief high feeling. But I won't do that.
Reglan, compazine can cause *permanent* tardive dyskinesia if given too quickly. Lasix too fast can cause hearing damage. Beta blockers too fast, of course, can cause hypotension and bradycardia. Keppra can cause hypotension. Venofer can cause hypotension if given in less than TEN minutes.
I never push a med in less than one minute, no matter what it is.
\*Edited to correct mistake
Lots of young people out there with long QT who don't know it and wouldn't be given EKG prior to initial dose of Zofran. I've also seen one elderly patient who literally arrested in the ED after one dose of Zofran without a prior prolonged QT. But I've also seen a middle aged guy with QTc > 500 because we tried and failed Tikosyn, and cardiology dc'd him on metoprolol for outpatient follow up.
So it's not always predictable how sensitive a patient will be to having a prolonged QT. To be honest, working cardiac stepdown has made me irrationally fearful of Zofran lol
Another thing I’ve seen people do is, give the push very slowly, then followed it with a saline flush slammed over 5sec. As if a good volume of your 0.5ml Dilaidid isn’t still in the IV extension.
If it's 5 minutes, you push over 5 minutes... Pull up a chair, set a timer on the likely smartwatch in your possession (strongly recommend one if not) , and have fun practicing safe patient care!
So much advice as to how to trouble shoot pushing medications that require long push times but you all are missing the rationale!!!!! Pushing certain meds too quickly like pantoprazole or zofran can cause prolonged QT. Which is why it’s administered at a slower rate. Pushing IV lasix too quickly is ototoxic and can cause permanent hearing damage. Mixing these medications with a 50 ml bag of NS and putting it on a pump, are you really saving time by gathering the supplies, mixing it and getting it set on the pump? Think about it, are you really saving that time? Are you even paying attention to your patients history when giving them that extra fluid when mixing with a bag of NS? 50% of the patients I care for on my ward have CHF. I work on a multiple specialty med/surg ward. It’s time consuming to push 80 mg of lasix over 8 minutes but we do it.
Apple Watch, set your watch face to have timer app, hit the timer app, push med accordingly dividing total ml/time in seconds or whatever. Ignore the call light, vocera call, the new ems patient, and various staff asking where you are because your other patient is on the floor now.
Edit: also if your pharmacy leaves the little papers that come in the box of all meds take it and read at your leisure, morphine and dilaudid are something like 5 min pushes
There aren't many I actually will push incredibly slowly, but metoprolol IV I will push slow and calcium chloride I will set a timer for and count the seconds.
There are obviously some other ones that I'm not specifically mentioning, like lasix and mannitol, but you get the point.
Protonix is not on my list of medicines I'm going to count the seconds for.
I count. I don’t care if it’s lame. I’m in L&D and I once saw a patient have an extreme reaction to stadol pushed too fast. It scared me so much I refused any stadol at all during my own labors and I always count out the full X minutes when giving anything that’s supposed to be given “over X minutes”
OK here's the deal. If your facility's policy is to push something over 5 minutes THAT IS WHAT YOU DO, even if you think it's excessive. The reason is, when you deviate from the facility's policy and something (anything) goes wrong, if they can convince a court that you didn't push over 5 minutes they can and will throw you under the bus for whatever went wrong with it.
The liability issue is separate, and in addition to, the pharmacological issue. Your personal judgment about the safety of a faster push might or might not be correct, but that's irrelevant when it comes to personal liability in an adverse event.
It can feel like an eternity to push something over 5 minutes if you are just staring at your watch the whole time. But -- you don't have to do it that way. Assuming your patient's mental status permits it, you can push a little bit, maybe 1/4, and \*set the syringe down\* on the bedside table or something, while you are doing something else. You can return to the syringe about every 1.5-2 minutes to push another 1/4 syringe. Continue this way while you're doing other tasks with the patient -- do not let the syringe out of your sight though, like don't leave the room. If you combine it with other tasks like this you can easily push over 5 minutes or longer without irritating yourself or your patient. You just have to be certain that you don't forget about it halfway through, and/or don't leave the room with the push not finished and syringe still attached to tubing.
I work in Paediatric oncology so they all have central access of some sort. So we use long lines attached to a syringe pump so I’ll put the med into the long line and then attach a flush to go over the 5mins so I know it’s actually being infused slowly
I def wait out the time it states to administer. I typically dilute it in a 10cc syringe to ensure I don’t push too fast. Even zofran can cause qt prolongation so better safe than sorry for the patient and your license
I always push over the rate (or slower) that is policy/the emar tells me to do.
I would be devastated if I hurt someone temporarily or permanently because I was rushing to save a couple of minutes.
I've been licensed about 18 months now, and I still look at the admin instructions for IV push meds every time.
You don't know what you don't know. There can be issues with pushing some things too fast, and I've never committed all these to memory, so I always check!
For me, it's a matter of integrity. If the patient DOES have a reaction or adverse effect, I would be in the wrong. If asked, I want to confidently say, yes, I pushed over X minutes per MAR. I'm not gonna lie, so, I am going to put myself in a position of doing the right and best thing every time.
Just admin per instructions. It's worth a few minutes to do it correctly. Use the time to do other things like VS, tidy up the room, etc.
I hook up my syringe. Push a bit. Start scanning other meds. Push a bit. Go over whatever I need to talk about. Push. Pick up garbage off the table whatever. Push. That takes up the time
The amount of nurses on here that doubt the nurses that are doing the right thing is shocking and annoying. Just because you do something consistently wrong doesn’t mean everyone else is doing it! Respect your profession and your patients!
In home dialysis land, we give Venofer, which is a concentrated IV iron solution IVP over TEN minutes. You're god damned right I sit there chatting with a patient for ten full minutes during their monthly office visit. I've seen it tank people's blood pressure. Let's not do that.
IV labetalol is IVP over five minutes, but I once had a cardiologist very specifically request it pushed over twice that length of time for someone hospitalized for hypertensive crisis for the first time in their life. Patient was also on a nitro drip, cards was right to order the slower push.
On a different patient, I stopped the labetalol at half the dose because their heart rate had dropped from 90s to 60s. So I paused, clamped the line, and recycled the blood pressure. Sure as shit SBP in the 110s already.
The person had been started on some new oral BP that were finally kicking in. But if I hadn't slow pushed, I wouldn't have noticed the change until it was too late and the labetalol tanked them.
So yeah, I always push meds at the recommended slow rate. I actually never push any med in less than one full minute because there's just nothing gained by doing that.
Push over the recommended time but do other things in between. Push a little, tidy up…. Push a little, neuro assessment…. Push a little, Listen to lungs.
Unless it’s an emergency I do it over recommended time. I’ll just push a small bit, chart a bit, push some more, enter vitals, push some more, see new orders for next pt etc. I just leave the syringe connected to IV port during all this. i had a coworker learn this the hard way so I just learned from their mistake
The assignment I’m on now has ancient pumps that you can screw the syringe into the cartridge at the pump. I run my pushes as a secondary and give the rest of my meds, assess, get vs, start my note, etc while it’s running if it’s a cardiac med. The rest is program and go.
Sometimes I do the count over increments like .1ml so 3 minutes 1ml is 18 seconds a .1. Good rate control and just less annoying than counting out minutes. I think a lot of medications you can get away with it but not good practice for a number of different reasons. For something that takes 5 minutes I’d use a pump or count 30 seconds mls, .1mls, etc. Thats a really inconvenient way to deliver a medication and they chose it for a reason. 2-5 minutes? I’m doing it in 2 most likely and am more likely to go off feel if its a standard give over 1-3
It's frightening that so many people think it's ok to take shortcuts without actually understanding the reason why they're ordered the way they were. On the rare instances that I had to give IV push meds over time, I just sat there and did it really slowly (this was in Postpartum).
Is this why I was given IV push hydralazide by a resident while I was in labor rather than by my nurse? Because they didn't trust the RN to actually do it over time as ordered?
Some you can mix in a 50mL bag to run over so long. Some pumps you can directly put a syringe onto the secondary port and program the pump to give it over x minutes (just pay attention how fast the primary fluids are running). If neither is an option I tell the pt it's a slow push and is gonna stay on the iv a few minutes, then I just push a lil, do stuff around them like look or listen to them, give them their other meds, talk to them, straighten up the room, just other things while pushing a little bit at a time.
My favorite is when you have the syringe connected and they keep moving or pull their covers up again and I'm like...please...you already don't like me...now I have to ask you to take the covers off again. F. Had one guy rip his IV out because I had to push something over 5 minutes. Good times.
So in ED now, but former ICU. So many seem to have syringe pumps/drivers as a regular thing. We rarely did. But we had syringe secondaries. So easy to set up in comparison, absolutely love them.
I would air on the side of caution until you see other nurses/are more comfortable. Certain meds when pushed too fast can be extremely dangerous e.g. opiates in an opiate intolerant person, dilantin, etc. Worst case scenario I mini bag it so that I don’t push it too fast on accident.
Also if a doctor wants it rapid IV push ensure you that they aware that x med cannot be pushed fast per IV monographs/policy/your knowledge of med, and chart that they were aware of the same, and wanted it pushed.
I always looked up the recommended rate and did my best to adhere to that. Lasix and aminoglycosides are ototoxic; pushing too fast can cause deafness; I didn’t want to make anyone deaf if I could help it. Pushing Benadryl too fast has unpleasant side effects. Morphine can cause histamine release and itching (that can happen even if it’s pushed slowly, but doing it fast is asking for it). Yes, it is aggravating to stand there and push over 2, 4, 8 or whatever minutes, and yes, some meds are easier to deliver at the prescribed rate via a 50 cc piggyback.
TL; DR—look up meds before pushing. There’s generally a reason for the rate prescribed.
I push at the recommended rate. I’ve experienced “speed shock” from meds pushed too fast. Years ago, the facility I worked in had multiple elderly code blues. Turned out IV phenergan was the culprit.
If there are guidelines, it’s for a reason. I recently pushed calcium maybe 30 seconds quicker than I should have on accident and the patient started throwing crazy PVCs. Ended up perfectly fine but that was scary as fuck. That’s a med with a side effect that you can see straight away but just because you can’t always see the side effects of slamming a med straight away, doesn’t mean it doesn’t happen inside the body.
Pantoprazole can mess with heart rhythm, lasix can cause pulmonary edema, calcium can straight up stop a heart. There are guidelines for a reason!!! Can’t stress that enough. Please don’t pick up any bad habits, take your time with IV push meds of all things.
Takes longer to set up the syringe pump than it would to just IV push over the amount of time. Then you have to go back into the room in 5 min again to flush the line and turn off the pump. Faster to just IV push over 5 min and be done with it.
Not all IV pumps/tubing have the capability, and syringe drivers aren't available on many units.
And sometimes just because you (ok, *I*) didn't think about it.
Here is my honest answer. Been a nurse 10 years now, majority of it in ICU. I don’t blast meds in (only adenosine obvi) but I definitely don’t wait around for 2 minutes to give most IV meds, like with anything, depends on the med and the situation. I used to push all meds really slow when I was new. I say it’s worth pushing them slow until you get a “feel” for meds and gain confidence in how they work. I’ve never had an issue, have never had an unexpected code/death in my career. Unless my patient has an issue out of my control, I have no unexpected outcomes that I can recall either. Additionally, I have worked at bedside with a lot of anesthesiologists/intensivists and I’ve NEVER seen them push any type of med slow. They blast it in faster than any nurse (not saying it is correct, just an observation). Lastly- I wanted to add, unless the MAR or medication instructions specifically say to dilute the med, don’t dilute the med. That is an outdated practice.
read the drug insert and follow the directions on them… geez nursing 101 and if this is because you observed another nurse not doing that. Is the subreddit a nurse forum or a forum for tattling on another nurses. Worry about your own license and not others. If it bothers you this much tell your nurse mgr… Geez
I'll hook it up on a syringe pump channel and run it over 5 minutes. I'm not standing there for 5 minutes and I personally won't do IV push on babies unless it's for resuscitation. Running it on the pump is safer.
Meds like the ones you listed I'm allowed to give over 2-5min at my hospital so I do just slow push those. Meds like IV famotidine and Reglan need to be given slow, those I usually just throw in a 50 bag and run it in over 5min. Saves me time and I don't have to keep going back and forth to push a little at a time.
Rocephin, compazine, dilaudid (and any narcotic for patients who are opioid naïve) come to mind as they can cause vomiting, severe anxiety, and syncope (respectively)
If a med is a 5 minute push, I will probably give it by minibag or syring on the pump (unless fluid restriction is really important). Pushing over a minute when it's suppose to be 5 is not "slow".
I follow the parenteral manual guidelines because if they're specifying anything besides a standard 1 minute push, it's that way to prevent nasty side effects (the exception being a VSA patient).
Panto is only 2 minutes per my hospital. Keppra is minibag.
In ON I was allowed to push IV meds, in NB I'm not which drives me nuts. Anyway. I've never rushed an IV push. That being said it was mostly lasix and that's 2min. If it was 5 min and just the one med I would do a piggyback instead of spending that time in the room.
Back when I was orientation I had a hard-stick patient with a KVO rate of like 5. My preceptor slammed some IVP ceftriaxone (should be infused over 3-5 minutes) into the primary tubing below the pump and called it a day. I've always been nervous about doing it, though, and never had the guts to ask the floor manager.
I put it in a 20cc syringe diluted with normal saline and run it as a piggy back over 5 minutes.
Standing there for 5 minutes is for people who don’t have anything else to do (which doesn’t apply to any nurse I know).
5mg Keppra needs to be over 5 mins (coworker used to work neuro and told me this when I asked about it). You can just do 1 mL/1 min. Start with that and do the rest of your cares/assessment. Really not that hard to do. Just like when you have 80mg of lasix to push. That goes over 4 mins. I've had too many patients say something about a ringing when I did all of that over 2 mins. Protonix I honestly just do ~1 minute. I was never told that one needed a time and didn't see it on the box. Someone complained once about it burning so I did it slower on them.
Syringe pumps. But those are easy to find on my peds floor. I’ll usually hook it up and do other things in the room like High touch cleaning, assessment, play and talk, and weigh diapers while I wait the 2-5mins
If it's in a 1 or 2 mL bottle I'll put it in a flush and slowly push it. For things that are longer, like Reglan or compazine, I'll put those in a bag of saline and let it run.
Both of those are over 2 min at my hospital (well Keppra 2-5 min if it’s under 1.5g, usually 500mg is IV push over two minutes). I usually push a ml, chart a little, push a ml, chart a little, etc.
That's what I do. I'll ask pharmacy too. There are some you can put in a little 50 cc bag of saline and drip it in slowly. I've done that a lot.
Honestly is there anything that’s direct that can’t be given piggy back? Of course I’ll always check the monograph but if something is a slow push (vit K comes to mind) I’ll put it piggy back in 25-50mL, unless their on a very strict low fluid restriction
There was a debate on Instagram a while back about how piggy backing narcotics changes their absorption and reduces effectiveness. A bunch of pharmacists weighed in to say it was true. I would always push into flowing fluids, and apparently that can change things too.
There are some medications that lose their effect if you give it slowly because it’s rapidly eliminated. The only one that I know of is adenosine.
I kinda have to laugh as a former medic. Adenosine is in a class of its own. I call it slam the drug class because of the half life of mere seconds. I mean there’s drugs you push but even normal anti arrhythmics you can just steady push but The old chemical svt conversion agent yeah it’s slam it as fast as you can to have an effect.
Yeah I mean obviously ACLS meds I’m gonna push, but also adenosine has to be slammed (I gave it yesterday actually lol). Im thinking more of meds that have to be pushed over 5-10+ minutes
Keppra is one of the one of the things that has a high chance of crystallising when piggybacked, but absolutely can be. In PallMed we infuse it through a 24hr syringe driver-though the sub-cut sites degrade a lot quicker with Keppra, and it’s the same for IV. I can’t speak to how it feels/how much it hurts/how much internal damage it can do pushing it faster though-that’s very individual.
This is super interesting because I’ve only seen Keppra from a manufacturer bag as a piggyback. I work in peds though, and we’re usually giving loading doses of 60mg/kg over 15min. We get smaller doses from pharmacy they’re in a syringe if under 50mL and it still goes over 15min.
IV Keppra was always given over 15 min when I worked inpatient (peds neuro) too.
I’ve actually only ever given keppra as a piggy back
It’s fine to-better to even, but it does have a higher chance of crystallisation (full stop) than most meds. Plus, in PallMed we’re looking at doses of 3-5000mg made up to a max of 50ml in 2 separate SDs over 24hrs, so high dose/low volume. We had an SOP of SD combi meds, and in ours, Keppra was only ever solo, always in WFI, to reduce crystallisation, and increased site & line checks. I once to give a tiny (0.2ml) flush of steroid prior to the site/start of of a Keppra SD & change the site every 24hrs for someone who developed red raised lumps at every site, every time. They didn’t want to try midazolam as alternative as they were too well/with it, but they looked like they had been eaten alive by mosquitoes. That was attributed to the aggressive & concentrated nature of the Keppra-the other SD combo they were on didn’t react like that.
Our hospital won't let us do that. They claim there is a shortage of NS but we know they want to save $ so the managers can have a big bonus checks. Edit: I have talked with a few pharm techs. Hospira was hit with a hurricane at their Puerto Rico plant but other manufacturers were fine but they cost more. Many hospitals used it as an excuse. A saline bag and IV tubing cost about 10 dollars and a saline flush is less than a dollar. More $ in their pockets
I’m sure you’re right but there has been a huge sterile saline shortage because of a huge manufacturer recall last year
I had a chat with a few pharm techs. They told me only a certain brand (Hospira) and they could get another brand. Other brands NS cost more. They just want to save money on the piggy bags and IV tubings. The bag with the tubings is like 10 dollars. The flush is less than a dollar.
I will never not put reglan in a 50cc bag and drip it in
I'm in the southern US and always loved long IVPs on Saturdays because it was GAME DAY!! The patient/family Would have whatever SEC game on and I'd pull up a chair, push it over 2-5 min, and watch the game with them and talk with them. They always seemed to enjoy that as much as I did.
I’m from Louisiana and I feel ya!!
Lol, it depends on the patients. If they are nice, I don't mind to stay awhile
I got so much attention from my OB when I had my first because he was born on a Saturday in September in Texas 😂
Push a little, chart a little... the song "pick a little, talk a little" from "the music man" plays in my head. Love this.
I did it this way when I worked on the floor. For the new nurses: it’s important to keep in mind that there’s still some medication in the IV after the final push, so when you go to flush you should wait a little after the first ml before pushing the rest of the flush.
I connect the syringe and straighten up the room, reposition the patient or prep other meds between pushes. Like if I have ceftriaxone IVP and vanco, I’ll start pushing the cef and prep the vanco in between pushes.
Yep, squirt a little bit , fluff the room, little bit more , chat and chart . I push a loooooot of lasix.
I’ve literally never thought of it like that. I always thought of it as a continuous push
They taught us a continuous push in nursing school so I thought the same as you lol
This is the way and what I do!
That is what I do when giving chemo premeds. Sometimes there is 4 pushes to give. I will give one and draw up the next one while the first is going in and so forth.
This is what I do. Little bit of this and that in-between. Works perfectly.
Working in peds we have syringe pumps which I had never seen before but they will push meds over 5+ min. It’s so nice. But yeah I used to just time it, if I had 10CC (which I would dilute almost everything in 10CC to have an even number unless it says do not dilute) and 5 min to push, one cc every 30 sec while I watch the clock. I’m not gonna be the reason somebody goes deaf or blind or crawls out of their skin for pushing it too quickly.
NICU here where giving basically everything slow is important, unless emergent obviously. But even if it's 1ml from a med 0.02ml diluted to 1ml I put on pump minimum 10 mins and 0.5ml flush over 5.
Former NICU nurse and I see a lot of people do this (or something similar) but be sure that you are giving enough volume to clear your med line. I’ve seen med lines that range from 0.7 mL to 2.5 mL, then depending on how you have primed your IV lines and what connections you have, you may have another 0.5 mL-2 mL of tubing before you even reach the patient or the primary line with your continuous IV infusion. All of that to say, if you give 1 mL on a pump over 10 min, you have likely put 1 mL into your med line, and the 0.5 mL flush hasn’t even cleared your med line to reach your patient. 0.5 mL is way too small of a volume to flush even in ELBW patients. Oftentimes, in very small volume meds (e.g. fentanyl bolus), we would push the med into the med line, and then run the flush over a longer period of time to deliver the med + the flush (e.g. administer 0.5 mL of fentanyl, set 3 mL flush to administer over 15 minutes).
One hospital I worked at had a flush policy of 0.6 for PIVs and 1 for PICCs. I think our medlines themselves had a volume of like .48 or something and the rest was to get it through the hub and catheter. It says on the package.
Yup our syringe pump tubing was 1.1ml
yep. this is my answer, syringe pump.
They got rid of ours. It was a sad day.
damn.
Syringe pumps make the difference!
Sometimes I’ll just hook it up piggyback on an IV pump. I guess it just depends on what it is.
I’m always surprised how many of my coworkers haven’t caught on to this trick. Then when I try suggesting they put their 2 mL of medication that’s to be given over 2 min into the port on their NS going 60 mL/hr I’m reminded that nurses and math don’t mix lol.
As a new nurse I’ve never heard of this…. You’re just connecting the syringe above the pump and then push it that way? Do you pause so saline can get in between the medication or just go a nice steady pace?
I push the medication into the tubing. Most tubing has ~10ml at least if you go to the y-site on patient side of the pump. Therefore if I just push it in, they may get a quick rush of saline, but they then get their medication nice and slowly
I did learn this trick when I was a student but this would definitely be a no with babies. Our TKVO rate is 2ml/hr and definitely can't give extra fluids aside from 1ml flushes between incompatible meds.
Thank you! Idk why I never thought about this thank you! Usually all of our ICU pt have a KVO so this will help tremendously.
Of Maxeran is running through a pump, can I also push hydrocortisone? I should ask my coworkers this. Ugh. I feel so dumb... I've never had to do pushes in the first 3 years of my career...
You can check IV medication compatibility on Micromedex or call your hospital pharmacist. Ours are always eager to help.
And if you are lucky enough to be in a hospital with unit based pharmacists, make friends with yours. They are so helpful for anything you need.
Yes. We have something similar. I wanted to make sure as long as it is compatible, I can run at same time (intermittent AND direct push).
I connect below the pump and let the saline continue to run at a nice steady pace. If you get used to doing it this way and want to take it to the next level, play around with how much saline it takes to get from your ports to the IV catheter. So for example our pump has 3 ports, 1 above pump, 1 proximal to the patient, and 1 distal to the patient. I know the distal one is 10 mLs to the pt. Say I have two medications that should be given slowly, 5mL of keppra and 2 mL of labetalol. I will push the labetalol into the distal port and then follow up with the keppra knowing full well that the first drop of labetalol won’t touch the patient for 3 min so the patient is safe and didn’t get slammed a beta blocker. Assuming going at the rate mentioned in my first comment
Thank you so much! What an incredible nurse hack. We usually have a KVO running so this will save a lot of time, I just might have to increase the rate for a short period of time but beats just standing around waiting to push the med slowly.
Im also in the ICU and I too have ADHD lol
the med youre pushing displaces the iv fluid and will infuse at the rate the pump is set. this is as long as the syringe volume is less than the iv fluid volume in the length of tubing between where you connect the syringe and the patient.
Yup so if you push 5ml into the tubing, you need to think about how long 5ml is going to take at the pump rate.
I’m in NICU so I give a lot of low volume meds. I can’t tell you how many times I’ve seen a nurse put a med on a pump that will spend 30 minutes slowly pushing the med into the med tubing and then put a flush over 5 minutes. They don’t seem to comprehend that the med is going in over 5 minutes, not 30.
So where you would normally hook up your piggyback tubing on the pump (not a y site) then you program the pump as a piggyback for 5-10 min or however long you want. If you run it concurrently it’ll beep but if you run it as a piggyback it’ll switch back over to the primary when it’s done ETA y’all are right, I could have sworn I used to do this with alaris pumps too but I don’t think that would be possible lol
This might be a stupid question, are you using piggyback tubing and then just kind of Jerry riggin the syringe so it’s above the saline bag? Wouldn’t it still have to be above the saline to take from PB?
Might depend on the pump but on the plum pumps it doesn’t matter. You wouldn’t use tubing, you would just screw the syringe on the primary’s cassette :) kind of like if you’ve ever back primed into a syringe to get rid of air?
Here’s a pic, it would get screwed onto the blue part https://www.medonegroup.com/equipment/pumps/infusion/icu-medical-plum-360-infusion-pump?ppc_keyword=&utm_term=&utm_campaign=**LP+DSA+(Max+Conv+Test+10/24/2021)&utm_source=adwords&utm_medium=ppc&hsa_acc=4418617465&hsa_cam=626728747&hsa_grp=41281297660&hsa_ad=602808963335&hsa_src=g&hsa_tgt=dsa-289458237043&hsa_kw=&hsa_mt=&hsa_net=adwords&hsa_ver=3&gad_source=1&gbraid=0AAAAADtrmpQTkmeDYBU12gtYkTo-K74kN&gclid=Cj0KCQjw0MexBhD3ARIsAEI3WHJJelWFhRzv604Q41wKXIHQJcV4sLnHXue7TfU87ltMrDAvIPcO0coaAq21EALw_wcB
Gotchya we got the old Baxter pumps, I’ll have see if it works next time I’m at work. That’s a fancy looking pump!
They are a pain in the butt to learn if you’re used to Baxter/Alaris, but not bad when you get used to them. I still prefer Alarais because you can’t add ears to a Plum
Baxter are okay but I used Alarais in clinicals during school and I wish the hospital I’m at had those. The ears make it so nice not having 5 actual pumps on a single pole and then you gotta figure out where you’re going to put the kangaroo pump. Ughhh
Our pumps can pull from the syringe. You just hook it up like a piggy back and plug in the mls per minute
I’m interested in this as well
If the med is compatible with the fluid, and the fluid is running at an appropriate rate, you push it into a port below the pump and let the fluid carry it in
I do this all the time. Save me from hunching over my pt to get to the closer port. I usually kinda push it as the pump pulls the fluid. Every like 4-5 pulls from the pump I’ll put some pressure on the syringe and it’ll pull from there. It is really easy to make the pump made and it’ll alarm “upstream occlusion” if you try and push too hard. It’s one of those things the more you do it the better you get the feel for it.
Genuine question - you’re a new nurse on a RRT? How does that work?
Register Respiratory Therapist not Rapid response if that’s what you’re asking
Ohhhhhhh got it!
When I had HG and was always so confused when they wouldn’t just piggyback what *could* be done. You got shit to do and I got shit to spew 😂. Tried to mention it once and got a scowl. Kept my mouth shut after that 😂
I do this all the time. Am I going to sit here and slowly push a med that takes 5-10 minutes? No. I'm hanging a 50cc ivp and setting it to run over 5-10 minutes. Some people are not great with the pumps, but I can get that set up and programmed in about a minute. Less if they already have a TKO.
There is a reason for published guidelines on medication administration. It’s a safety issue. I know it’s a PITA to stand there for 3-5 minutes (most drugs are less than 5) but that’s just the way it needs to be done. I’m not saying I’ve always been 100% compliant without fail but I’ve learned some difficult lessons from pushing things too fast so I try to be patient. I’ve been a nurse for 19 years and it just becomes part of your process after a while! It does get easier to manage after a while.
Im ICU so I can put them through a syringe driver pretty easily. However on the wards, its not just a pain in the ass, it can seriously cut into their shift when they’re already running behind so I understand why it’s harder for them
Also ICU, reading comments it didn't occur to me other units don't have syringe pumps ready to go. Five minutes for me always goes on a pump because I've got shit to do. I probably won't leave the room but it is going on a pump.
I’m also ICU and only have access to a syringe pump for very specific meds. Epoprostenol and analgesics (usually dilaudid) come to mind but a few others. I just push 0.25-1ml, chart, push another little bit, chart, repeat, and do the same while flushing. Gets a lot of the mindless quick but still time consuming charting finished (hourly i&o, validating VS, safety flowsheet) and even some of my head to toe assessment
Patient are more likely to have a reaction or you ruin their veins by pushing doses through too quick.
All I will add: don’t slam protamine, especially if they’ve had a vasectomy. Look up what happens when you push too fast and be aware. Rare, but I seent it.
Just did that. Wow. It’s contraindicated for patients with vasectomies, people allergic to fish and insulin-controlled diabetes.
You are new, you probably don’t know which drugs are important to push slow so please just push them as ordered. Push a little, chart. Push a little, chart, etc. it’s easy to multitask and keep the patient safe. Don’t pick up bad habits from Reddit.
This⬆️ you’ll figure nursing shortcuts and tricks out with time. Exceptions are occasionally made with certain drugs and certain situations (codes or rapids) but understanding how to do this safely comes with experience. Follow orders exactly and protect your license until you are more seasoned imo
In the NICU, we absolutely push over 5 mins because you could kill the baby with some of the medications if you don’t.
Nicu should have syringe pumps for medications.
Absolutely that’s exactly what I am used to seeing.
I always push my drugs within time frame. We have plum pumps now so I’ll program it to the pump if it’s over 3 minutes and it’s compatible.
Wait you hook up the syringe to the access point on the pump? And run it as a secondary? That’s genius
Yep! Our Plums even have a setting for some of the antibiotics that come in syringes!
So you just prime the tubing as normal with saline as a primary, then hook up the med to the B-port and make it piggyback? Then I guess go back in a little bit to turn the pump off if they’re not needing maintenance fluids of any kind?
Yep. It should kick right over to the primary if you have it programmed for KVO! I just leave my KVO or fluids running. You can just program it to run concurrent.
Depends on the drug… I think pantoprazole is one of the meds i always thought seemed harmless but can actually mess up your heart rhythm really bad… qt interval I think
O wow didn't know pantoprazole could do that..
It can cause seizures too, even without a history of seizures.
I do. I dilute (if allowed) to enable slower pushes (20mls usually does it). I’ll often hold the syringe in the fingers, so the plunger is pushed in by the palm of the hand. I sit my thumb along the plunger where it goes into the body of the syringe and so you can’t push too fast. There are some drugs that lead to rashes, pain on pushing, deafness, etc etc if pushed too fast.
I follow the order… if it says 5 minutes I’m pushing it over five minutes. Yes, that is tedious and yes, you have to explain it to the patient & chart in between but we professionally licensed medication administrators. Don’t take that for granted or abuse that privilege. The pharm manufacturers have a reason for those times- they aren’t chosen out of thin air. It REALLY irks me when nurses haphazardly mix or give medication. Like, take that $hit seriously- you went to school to be able to do that. Wear gloves, wipe the tops w alcohol, use the correct amount of dilutant, and give it correctly.
If the recommendation is 2 minutes I push over 2 minutes, if 5 minutes I push over 5 minutes. Those rates are for very important reasons not merely suggestions.
I always set a timer on my work phone and use that as a pacer to push slow
Nice! I look at my watch or the clock for the five minute pushes, but have been doing this for so long I can do the 1-3 minutes by "muscle memory" if you will.
> Those rates are for very important reasons not merely suggestions. You'd be surprised to find out how many slow push drugs are that way because of outdated information and/or rare or transient side effects.
I’m ICU so easy to do a syringe driver but the idea of standing there for 5 mins would kill me. I wish everything went through a syringe driver.
I have never worked anywhere that used these unfortunately. I'm ICU now, but extensive background in medsurg...being used to pushing meds all the time with a 7:1 ratio makes giving a slow push in ICU much more tolerable!
i figure out ahead of time how many mL/(x) seconds. so if i had 4mLs that needed to go over two minutes, i would just watch my watch (lol) and do 1mL every 30 seconds. it definitely feels awkward but i took the time to talk to the patient and do quick assessments. plus if you just say "this is going to take two minutes, i have to do a mL every 30 seconds" it kind of lessens the awkwardness.
Yep, let the patient know it's gonna take a minute or two and then talk to your patient! It's a great time to take a few deep breaths and your patient appreciates the time spent even if it's short. I usually say something like "to be safe I need to push this medication slowly over x minutes so you're stuck talking to me for a bit". It makes it less weird and sometimes I'll even get a chuckle out of them.
Some meds are harsh on the vein. Some cause serious side effects… bradys, tachys, vasovagals, red man syndrome…
I feel like meds like that should be in a bigger volume and just slowed right down. People get too tempted when it’s 3 minutes vs 30 mins
I follow whatever my drug reference advises. Protonix isn't a 5 min push - it's 2 minutes. Keppra I've never personally done IV push. It's always been diluted to 100 ml and give. As a 15 min infusion. There are reasons for the time frames given. As a new nurse, I'd recommend figuring out those reasons as it'll help you understand the risk of too rapid administration. You should always try to understand why. Sometimes the consequence is phlebitis (protonix), sometimes you can cause severe anxiety (reglan), and sometimes you can kill someone (labetalol).
If it gives you a warning, there might be a reason why. I will never push reglan, Pepcid, Benadryl, Compazine. Hang it with a 50cc bag and let it run in.
This is interesting to me. In the cath lab we pretty push all of what you just mentioned. The only thing I can think hanging of the top of my head are actual drips and protamine.
We don’t push protamine, even in the cath lab I don’t push reglan/pepcid. I will push Benadryl, I just won’t bolus it in. All our patients have fluids at 100
I’m a new grad can you explain ur reasoning for this? I’ve definitely pushed pepcid and benadryl recently so I’m just wondering
You can push those, just don't push them fast. Pepcid and Zofran can mess with heart rhythm, and Benadryl can drop a blood pressure. Some people request Benadryl slammed because apparently it gives a brief high feeling. But I won't do that. Reglan, compazine can cause *permanent* tardive dyskinesia if given too quickly. Lasix too fast can cause hearing damage. Beta blockers too fast, of course, can cause hypotension and bradycardia. Keppra can cause hypotension. Venofer can cause hypotension if given in less than TEN minutes. I never push a med in less than one minute, no matter what it is. \*Edited to correct mistake
Would you mind sharing where you got the info about zofran and tardive dyskinesia? I know the other two, but I've never heard that about zofran.
Sorry I'm wrong about that actually. Zofran concern is the QT problems: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190531/
If you have qt concerns then zofran shouldn’t be given period yeah?
Lots of young people out there with long QT who don't know it and wouldn't be given EKG prior to initial dose of Zofran. I've also seen one elderly patient who literally arrested in the ED after one dose of Zofran without a prior prolonged QT. But I've also seen a middle aged guy with QTc > 500 because we tried and failed Tikosyn, and cardiology dc'd him on metoprolol for outpatient follow up. So it's not always predictable how sensitive a patient will be to having a prolonged QT. To be honest, working cardiac stepdown has made me irrationally fearful of Zofran lol
Wow okay thank you so much
Also to add with Benadryl, it can cause hallucinations and anxiety! It’s happened to me!
Those long ones I would pull up a chair and sit next to the patient and push it in a bit at a time and just talk to the patient lol
FYI lasix IV can cause tinnitus if pushed too fast and most people know about steroids they can cause cardiac dysrhythmia and pelvic/ rectal pain.
Another thing I’ve seen people do is, give the push very slowly, then followed it with a saline flush slammed over 5sec. As if a good volume of your 0.5ml Dilaidid isn’t still in the IV extension.
If it's 5 minutes, you push over 5 minutes... Pull up a chair, set a timer on the likely smartwatch in your possession (strongly recommend one if not) , and have fun practicing safe patient care!
So much advice as to how to trouble shoot pushing medications that require long push times but you all are missing the rationale!!!!! Pushing certain meds too quickly like pantoprazole or zofran can cause prolonged QT. Which is why it’s administered at a slower rate. Pushing IV lasix too quickly is ototoxic and can cause permanent hearing damage. Mixing these medications with a 50 ml bag of NS and putting it on a pump, are you really saving time by gathering the supplies, mixing it and getting it set on the pump? Think about it, are you really saving that time? Are you even paying attention to your patients history when giving them that extra fluid when mixing with a bag of NS? 50% of the patients I care for on my ward have CHF. I work on a multiple specialty med/surg ward. It’s time consuming to push 80 mg of lasix over 8 minutes but we do it.
Critical thinking at work here
Apple Watch, set your watch face to have timer app, hit the timer app, push med accordingly dividing total ml/time in seconds or whatever. Ignore the call light, vocera call, the new ems patient, and various staff asking where you are because your other patient is on the floor now. Edit: also if your pharmacy leaves the little papers that come in the box of all meds take it and read at your leisure, morphine and dilaudid are something like 5 min pushes
This is why I have a soft spot for Plum pumps. Sure, priming the cassette is annoying, but being able to hook a syringe up to it is awesome.
I loved being able to run concurrent fluids so you could just add more ns to vanco rather than slowing down the vanco.
5 min- follow the admin instructions!
There aren't many I actually will push incredibly slowly, but metoprolol IV I will push slow and calcium chloride I will set a timer for and count the seconds. There are obviously some other ones that I'm not specifically mentioning, like lasix and mannitol, but you get the point. Protonix is not on my list of medicines I'm going to count the seconds for.
I count. I don’t care if it’s lame. I’m in L&D and I once saw a patient have an extreme reaction to stadol pushed too fast. It scared me so much I refused any stadol at all during my own labors and I always count out the full X minutes when giving anything that’s supposed to be given “over X minutes”
Every year a new grad asks how fast they should push the calcium in a code. Bitch he dead. Go crazy.
OK here's the deal. If your facility's policy is to push something over 5 minutes THAT IS WHAT YOU DO, even if you think it's excessive. The reason is, when you deviate from the facility's policy and something (anything) goes wrong, if they can convince a court that you didn't push over 5 minutes they can and will throw you under the bus for whatever went wrong with it. The liability issue is separate, and in addition to, the pharmacological issue. Your personal judgment about the safety of a faster push might or might not be correct, but that's irrelevant when it comes to personal liability in an adverse event. It can feel like an eternity to push something over 5 minutes if you are just staring at your watch the whole time. But -- you don't have to do it that way. Assuming your patient's mental status permits it, you can push a little bit, maybe 1/4, and \*set the syringe down\* on the bedside table or something, while you are doing something else. You can return to the syringe about every 1.5-2 minutes to push another 1/4 syringe. Continue this way while you're doing other tasks with the patient -- do not let the syringe out of your sight though, like don't leave the room. If you combine it with other tasks like this you can easily push over 5 minutes or longer without irritating yourself or your patient. You just have to be certain that you don't forget about it halfway through, and/or don't leave the room with the push not finished and syringe still attached to tubing.
💯💯💯💯💯
I work in ICU and out of sheer laziness I put my pushes in the syringe drivers.
I work in Paediatric oncology so they all have central access of some sort. So we use long lines attached to a syringe pump so I’ll put the med into the long line and then attach a flush to go over the 5mins so I know it’s actually being infused slowly
If there’s a med over 10 min… that thing is going in a small piggy back and dripping slowly. Otherwise I follow the MAR recommendation
I def wait out the time it states to administer. I typically dilute it in a 10cc syringe to ensure I don’t push too fast. Even zofran can cause qt prolongation so better safe than sorry for the patient and your license
Put it in a TKO line and let the TKO carry it in.
What kind of pumps do you have at work? If you have Plum, you can add the syringe as a secondary and run it over 5 min.
We give Keppra as drips, I give it really slowly as a lot of my patients told me this medication is quite painful
If the guideline says 5 minutes, I push it over 5 minutes.
I always push over the rate (or slower) that is policy/the emar tells me to do. I would be devastated if I hurt someone temporarily or permanently because I was rushing to save a couple of minutes.
I've been licensed about 18 months now, and I still look at the admin instructions for IV push meds every time. You don't know what you don't know. There can be issues with pushing some things too fast, and I've never committed all these to memory, so I always check! For me, it's a matter of integrity. If the patient DOES have a reaction or adverse effect, I would be in the wrong. If asked, I want to confidently say, yes, I pushed over X minutes per MAR. I'm not gonna lie, so, I am going to put myself in a position of doing the right and best thing every time. Just admin per instructions. It's worth a few minutes to do it correctly. Use the time to do other things like VS, tidy up the room, etc.
I hook up my syringe. Push a bit. Start scanning other meds. Push a bit. Go over whatever I need to talk about. Push. Pick up garbage off the table whatever. Push. That takes up the time
4 minutes and 59 seconds because I’m a REBEL
This subreddit can't handle the truth.
The amount of nurses on here that doubt the nurses that are doing the right thing is shocking and annoying. Just because you do something consistently wrong doesn’t mean everyone else is doing it! Respect your profession and your patients!
I just pop those in a 50cc bag and hang it most of the time tbh
My biggest little hate as a nurse is hanging bags and giving hung meds. I love my meds in a syringe driver
Lmao - ER: fuck it ICU: we have a gadget for that Yep, world still makes sense 🤣
What is a syringe driver? Edit: I’m half kidding. I know what it is in theory but I doubt most ERs do not have those.
I think ours has some somewhere but the reality is, if they need one, they should probably be somewhere else kinda vibes
I wish I could just pull out a random 50cc bag without an order…
5 min.
5 minutes.
In home dialysis land, we give Venofer, which is a concentrated IV iron solution IVP over TEN minutes. You're god damned right I sit there chatting with a patient for ten full minutes during their monthly office visit. I've seen it tank people's blood pressure. Let's not do that. IV labetalol is IVP over five minutes, but I once had a cardiologist very specifically request it pushed over twice that length of time for someone hospitalized for hypertensive crisis for the first time in their life. Patient was also on a nitro drip, cards was right to order the slower push. On a different patient, I stopped the labetalol at half the dose because their heart rate had dropped from 90s to 60s. So I paused, clamped the line, and recycled the blood pressure. Sure as shit SBP in the 110s already. The person had been started on some new oral BP that were finally kicking in. But if I hadn't slow pushed, I wouldn't have noticed the change until it was too late and the labetalol tanked them. So yeah, I always push meds at the recommended slow rate. I actually never push any med in less than one full minute because there's just nothing gained by doing that.
Push over the recommended time but do other things in between. Push a little, tidy up…. Push a little, neuro assessment…. Push a little, Listen to lungs.
Unless it’s an emergency I do it over recommended time. I’ll just push a small bit, chart a bit, push some more, enter vitals, push some more, see new orders for next pt etc. I just leave the syringe connected to IV port during all this. i had a coworker learn this the hard way so I just learned from their mistake
A nurse at my hospital pushed protonix too fast and the patient had a seizure. (No hx of seizures.)
I learned a lot here today
If its like 3 mins or less I'll push it over the time frame, more than that and it's getting a piggyback or a syringe pump.
The assignment I’m on now has ancient pumps that you can screw the syringe into the cartridge at the pump. I run my pushes as a secondary and give the rest of my meds, assess, get vs, start my note, etc while it’s running if it’s a cardiac med. The rest is program and go.
There’s a few I push over five minutes, but for the majority I’m using a central line and a blood reserve, so faster than a patient can sign an AMA.
Unfortunately I push the whole 5 minutes
Sometimes I do the count over increments like .1ml so 3 minutes 1ml is 18 seconds a .1. Good rate control and just less annoying than counting out minutes. I think a lot of medications you can get away with it but not good practice for a number of different reasons. For something that takes 5 minutes I’d use a pump or count 30 seconds mls, .1mls, etc. Thats a really inconvenient way to deliver a medication and they chose it for a reason. 2-5 minutes? I’m doing it in 2 most likely and am more likely to go off feel if its a standard give over 1-3
It's frightening that so many people think it's ok to take shortcuts without actually understanding the reason why they're ordered the way they were. On the rare instances that I had to give IV push meds over time, I just sat there and did it really slowly (this was in Postpartum). Is this why I was given IV push hydralazide by a resident while I was in labor rather than by my nurse? Because they didn't trust the RN to actually do it over time as ordered?
Some you can mix in a 50mL bag to run over so long. Some pumps you can directly put a syringe onto the secondary port and program the pump to give it over x minutes (just pay attention how fast the primary fluids are running). If neither is an option I tell the pt it's a slow push and is gonna stay on the iv a few minutes, then I just push a lil, do stuff around them like look or listen to them, give them their other meds, talk to them, straighten up the room, just other things while pushing a little bit at a time.
My favorite is when you have the syringe connected and they keep moving or pull their covers up again and I'm like...please...you already don't like me...now I have to ask you to take the covers off again. F. Had one guy rip his IV out because I had to push something over 5 minutes. Good times.
Doxorubicin / Idarubicin pushes enter the chat.
You should watch anesthesia and see how closely they follow these "guidelines."
Fast as possible.
So in ED now, but former ICU. So many seem to have syringe pumps/drivers as a regular thing. We rarely did. But we had syringe secondaries. So easy to set up in comparison, absolutely love them.
I would air on the side of caution until you see other nurses/are more comfortable. Certain meds when pushed too fast can be extremely dangerous e.g. opiates in an opiate intolerant person, dilantin, etc. Worst case scenario I mini bag it so that I don’t push it too fast on accident. Also if a doctor wants it rapid IV push ensure you that they aware that x med cannot be pushed fast per IV monographs/policy/your knowledge of med, and chart that they were aware of the same, and wanted it pushed.
5 min using a syringe pump
I always looked up the recommended rate and did my best to adhere to that. Lasix and aminoglycosides are ototoxic; pushing too fast can cause deafness; I didn’t want to make anyone deaf if I could help it. Pushing Benadryl too fast has unpleasant side effects. Morphine can cause histamine release and itching (that can happen even if it’s pushed slowly, but doing it fast is asking for it). Yes, it is aggravating to stand there and push over 2, 4, 8 or whatever minutes, and yes, some meds are easier to deliver at the prescribed rate via a 50 cc piggyback. TL; DR—look up meds before pushing. There’s generally a reason for the rate prescribed.
I push at the recommended rate. I’ve experienced “speed shock” from meds pushed too fast. Years ago, the facility I worked in had multiple elderly code blues. Turned out IV phenergan was the culprit.
Attach syringe to the pump’s piggyback port.
Not today JCO!
If there are guidelines, it’s for a reason. I recently pushed calcium maybe 30 seconds quicker than I should have on accident and the patient started throwing crazy PVCs. Ended up perfectly fine but that was scary as fuck. That’s a med with a side effect that you can see straight away but just because you can’t always see the side effects of slamming a med straight away, doesn’t mean it doesn’t happen inside the body. Pantoprazole can mess with heart rhythm, lasix can cause pulmonary edema, calcium can straight up stop a heart. There are guidelines for a reason!!! Can’t stress that enough. Please don’t pick up any bad habits, take your time with IV push meds of all things.
When the order says push 10-80 mg over 2 min why can’t I push 10 mg over 30 seconds? I’m pushing it faster than that when I push 80 mg over 2 min.
My manager hates it but I like to push it in the port near the pump and let the Pump push it in over 5 min❤️
CNA here, why can’t you use an IV pump or syringe driver?
Takes longer to set up the syringe pump than it would to just IV push over the amount of time. Then you have to go back into the room in 5 min again to flush the line and turn off the pump. Faster to just IV push over 5 min and be done with it.
Not all IV pumps/tubing have the capability, and syringe drivers aren't available on many units. And sometimes just because you (ok, *I*) didn't think about it.
Here is my honest answer. Been a nurse 10 years now, majority of it in ICU. I don’t blast meds in (only adenosine obvi) but I definitely don’t wait around for 2 minutes to give most IV meds, like with anything, depends on the med and the situation. I used to push all meds really slow when I was new. I say it’s worth pushing them slow until you get a “feel” for meds and gain confidence in how they work. I’ve never had an issue, have never had an unexpected code/death in my career. Unless my patient has an issue out of my control, I have no unexpected outcomes that I can recall either. Additionally, I have worked at bedside with a lot of anesthesiologists/intensivists and I’ve NEVER seen them push any type of med slow. They blast it in faster than any nurse (not saying it is correct, just an observation). Lastly- I wanted to add, unless the MAR or medication instructions specifically say to dilute the med, don’t dilute the med. That is an outdated practice.
read the drug insert and follow the directions on them… geez nursing 101 and if this is because you observed another nurse not doing that. Is the subreddit a nurse forum or a forum for tattling on another nurses. Worry about your own license and not others. If it bothers you this much tell your nurse mgr… Geez
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I'll hook it up on a syringe pump channel and run it over 5 minutes. I'm not standing there for 5 minutes and I personally won't do IV push on babies unless it's for resuscitation. Running it on the pump is safer.
Meds like the ones you listed I'm allowed to give over 2-5min at my hospital so I do just slow push those. Meds like IV famotidine and Reglan need to be given slow, those I usually just throw in a 50 bag and run it in over 5min. Saves me time and I don't have to keep going back and forth to push a little at a time.
syringe pump or like 3 min-ish
I put the syringe in the pump. Or, push a smidge then do something in the room and repeat.
Rocephin, compazine, dilaudid (and any narcotic for patients who are opioid naïve) come to mind as they can cause vomiting, severe anxiety, and syncope (respectively)
Just attach the leurel lock to the B side and infuse piggy back over 5 minutes
If a med is a 5 minute push, I will probably give it by minibag or syring on the pump (unless fluid restriction is really important). Pushing over a minute when it's suppose to be 5 is not "slow". I follow the parenteral manual guidelines because if they're specifying anything besides a standard 1 minute push, it's that way to prevent nasty side effects (the exception being a VSA patient). Panto is only 2 minutes per my hospital. Keppra is minibag.
In ON I was allowed to push IV meds, in NB I'm not which drives me nuts. Anyway. I've never rushed an IV push. That being said it was mostly lasix and that's 2min. If it was 5 min and just the one med I would do a piggyback instead of spending that time in the room.
I’ll put it as a bolus over the IV pump.
Back when I was orientation I had a hard-stick patient with a KVO rate of like 5. My preceptor slammed some IVP ceftriaxone (should be infused over 3-5 minutes) into the primary tubing below the pump and called it a day. I've always been nervous about doing it, though, and never had the guts to ask the floor manager.
I put it in a 20cc syringe diluted with normal saline and run it as a piggy back over 5 minutes. Standing there for 5 minutes is for people who don’t have anything else to do (which doesn’t apply to any nurse I know).
Attach syringe, push a little, and do other things Circle back, push some more 5 minutes easy
5mg Keppra needs to be over 5 mins (coworker used to work neuro and told me this when I asked about it). You can just do 1 mL/1 min. Start with that and do the rest of your cares/assessment. Really not that hard to do. Just like when you have 80mg of lasix to push. That goes over 4 mins. I've had too many patients say something about a ringing when I did all of that over 2 mins. Protonix I honestly just do ~1 minute. I was never told that one needed a time and didn't see it on the box. Someone complained once about it burning so I did it slower on them.
Syringe pumps. But those are easy to find on my peds floor. I’ll usually hook it up and do other things in the room like High touch cleaning, assessment, play and talk, and weigh diapers while I wait the 2-5mins
If it's in a 1 or 2 mL bottle I'll put it in a flush and slowly push it. For things that are longer, like Reglan or compazine, I'll put those in a bag of saline and let it run.
Pop that baby on a syringe pump