I was watching my preceptee give Zofran the other day and I thought that he gave it a little too fast. I didn't have the stop watch on him, but I was looking for maybe 30 seconds to a minute for the small 4 mg in 2cc injection, and what I saw was about ten seconds. It wasn't a rapid adenosine push, but it was more rushed than it should have been.
Now let me confess that I have done the same thing. I have pushed drugs that I know are supposed to be pushed slow maybe a little faster than I should have. In the 911 world time can easily become compressed. 1-2 minutes becomes 10-15 seconds maybe in the same way that for some providers 8-10 ventilations in a minute become 20-30 ventilations.
After the call I cautioned him on pushing the drug slower and when I turned to the protocol page to show him that the drug was supposed to be pushed slowly, I saw in plain black and white that the drug is supposed to be pushed "over 2-5 minutes."
Surprised by this, I went to the drug insert and read:
"The recommended I.V. dosage of ZOFRAN for adults is 4 mg undiluted administered intravenously in not less than 30 seconds, preferably over 2 to 5 minutes."
My first reaction, was, well, I can at least go with "Not less than 30 seconds," but when I discussed the matter with an ED doctor, his reaction was I should do it in 2-5 minutes. Why? I asked. Because it says "preferably" over 2-5 minutes, he answered.
Good point.
Now I suppose if all hell is breaking loose - the patient is vomiting, having a massive MI, I'm by myself, trying to patch to the hospital as well as put in another line, maybe I could get away with 30 seconds. But if I was a regular patient with nausea and vomiting and I read that insert, would I want the drug over 30 seconds? or over 2-5 minutes?
I think 2-5 minutes. It's hard to argue with black and white.
I love reading drug inserts. You can find all sorts of fascinating information. For example it was a drug insert that confirmed a reader's tip that Nitrolingual spray can be sprayed on the tongue if you can't get the patient to lift up his tongue. I read in a drug insert that I had to dilute Ativan at least 1-1 before pushing it IV. And long ago I learned giving Lidocaine to a patient with a bifasicular block will kill them -- all things I hadn't known.
There is all kinds of information in drug inserts -- information about drug trials, side effects. Very interesting stuff. My only problem is the print is a little small for my aging eyes.
Anyway, this all has me thinking about drips. When I give Zofran in the future, I will give it by drip. If the patient needs fluid anyway, I'll just put it in a 250 saline bag and open it up. If they don't need fluid, I'll let 200 cc out of the 250 bag and put the Zofran in the remaining 50. (We're out of 100 cc bags right now).
Back in November 2007, the following article appeared in JEMS:
Is D50 Too Much of a Good Thing?
The point was when faced with a hypoglycemic patient, instead of giving them D50 through an IV and risking tissue necrosis and too rapid an absorption of Dextrose, it would be better for the patient to put the D50 in a 250 cc bag (you would have to let out 50 cc first) and then run the whole bag in as D10. The other good part of this is it makes it much easier to titrate to effect. Some patients won't need the whole D50. (I can't find the D50 insert, but an internet site suggested D50 needs to be pushed much slower than I think many people push it -- as fast as it will push).
For peripheral vein administration: Injection of the solution should be made slowly. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused ata rate of 0.8 g/kg/hr.
I've asked a couple brittle diabetics about their preference between the thick syrupy D50 and the more watery D10 and they have said they would prefer getting the D10 to the D50 which often leaves them with a headache and rubbing their veins.
I'm trying to view things from the patient's point of view, which I do sometimes, but maybe not as much as I should. I'm also going to try over the next couple weeks to look at all the drugs we carry and find the proper push method and maybe compile a best practices list. While each situation will be somewhat patient/scene driven, I'd like to follow the "preferable" method as much as I can. I just read the Benadryl insert and it says no quicker than 25 mg/min, which would be two minutes for someone getting a 50 mg dose. I'm going to need to slow that one down, too.
***
Update: We had a chemo patient today with nausea. I watched to see how my preceptee would give the Zofran after we had talked about it. He gave it slow IV push over two and a half minutes. It was a fairly straight foward call so after he had put her on the monitor and gotten the IV there wasn't much else to do. He chatted with the patient as he pushed it slowly. She soon felt better.
