RSI Intubation for Nurses: Rapid Sequence Intubation

RSI Intubation for Nurses: Rapid Sequence Intubation

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

RSI, or Rapid sequence intubation, is the process where we intubate people in the hospital, pre-hospital, and emergency department settings when the patient is awake.

It involves multiple different steps that need to occur to quick succession, to provide first sedation, then paralysis, then insertion of the endotracheal tube into the trachea. 

Learn all about RSI intubation, and specifically what the nurse’s role during an intubation is, and which compications and montioring parameters to watch out for!

RSI intubation: rapid sequence intubation for nurses Featured Image

Indications for RSI Intubation?

So when does a person need intubed? Well, this really depends, but emergent intubations often involve severe respiratory distress

Patients in acute respiratory failure will typically present with:

    Tachypnea

    Increased respiratory rate > 20 rpm

    Hypoxia

    SPO2 < 90%

    Increased WOB

    Increased work of breathing characterized by use of accessory muscles

    Adventitious Breath Sounds

    Presence of abnormal breath sounds including wheezing, crackles, rhonchi, or diminishment

    Other Abnormal Vital signs

    May be present including tachycardia, hypertension, hypotension, fever, or altered mental status

    Tripod position is when a patient is sitting over the bed leaning forward, supporting their upper body with their hands on the knees or another surface. This helps accessory muscles breath more easily, but can be an ominous sign to someone who is in respiratory distress. Think COPD!

    Indications for Rapid Sequence intubation (RSI intubation) includes:

    • Acute Respiratory Failure (from pneumonia, COPD, CHF, Covid, etc)
    • Anaphylactic reaction or Angioedema
    • When the patient cannot protect their airway (severe alcohol intoxication, drugs, etc.)
    • For surgery

    The Nurses Role during RSI

    So what is YOUR responsibility as the nurse?  Well don’t worry, you shouldn’t actually be the one to intubate the patient (although there are some exceptions such as NICU nurses and Flight nurses). 

    The person who placed the Endotracheal (ET) tube is usually a paramedic, physician, and sometimes an advanced practice provider (PA, NP, or CRNA). This is usually:

    • EM Physician but sometimes APP
    • IM Physician
    • Anesthesia

    The nurse’s role is not to physically intubate, but nurses are essential in making sure the intubation goes safely and smoothly. They are also on the front lines to notice and intervene when things go wrong!

    The nurse’s role is to prepare the patient and equipment,  administer the medications, help manage the airway (although this is usually the job of respiratory therapists), and monitor the patient.

    Afterwards, they are required to keep the patient sedated with titratable sedatives.

    It is still important for nurses to understand how the RSI intubation process goes, even if they are not the ones placing the ET tube. It takes a team of nurses, respiratory therapists, physicians, and more to have a successful intubation without any complications.

    Alternatives to RSI intubation

    Are there any alternatives to intubation? Yes and no. 

    There are certainly treatments we can try before jumping to intubation. These include nebulizers, certain IM/SQ meds, a non-rebreather, High-flow nasal cannula, and CPAP or BIPAP.

    However, usually when intubation is decided on, it is when the patient is in impending respiratory arrest, or when the other treatments already aren’t enough. 

    RSI intubation is kind of our last saving measure that we can do to save their life and stabilize their respiratory system. 

    RSI Medications

    Before diving into the steps of RSI, we need to review the important medications that are given during RSI.

    It is the nurses responsibility to draw these up, reconstitute them, and give them. Any medication that a nurse gives, they should know how the medication works, any side effects, and what to monitor for.

    Sedatives

    First we’re going to talk about sedatives. A sedative is a medication that acts as a CNS depressant – essentially putting the patient to sleep. Different sedatives work in different ways. Sometimes, it takes multiple different sedatives at the same time to effectively sedate a patient.

    Sedatives are also called induction agents – inducing sedation in the patient. They also decrease the sympathetic response, making the body better tolerate the overall intubation experience.

    In regards to RSI Intubation, SEDATIVES ARE ALWAYS GIVEN FIRST

    This is because you need to knock the patient out before you paralyze them, as this is a very frightening experience if not. It can also cause tachycardia, hypertension, and increased ICP if you don’t!

    Etomidate

    Etomidate is the most common sedative that will be ordered for RSI intubation. 

    Etomidate does not offer any analgesia, so sometimes fentanyl is added to minimize the SNS stimulation for patients with significant cardiovascular disease or increased ICP patients.

    Etomidate does not really affect blood pressure, but it can cause some mild increase in airway resistance.

    Side Effects & Monitoring

    Myoclonus

    Etomidate can cause myoclonus to occur, which is brief and harmless, but can be mistaken for a seizure.

    Adrenal Suppression

    Etomidate can cause adrenal suppression for 12-24 hours after the injection. This could potentially impact hemodynamic stability (blood pressure), mainly in patients who are at risk such as those with pre-existing adrenal insufficiency or severe sepsis.

    Patients with severe sepsis who are intubated with etomidate and become hypotensive despite fluids and a vasopressor should be given a 1x dose of hydrocortisone 100mg IV.

    Heart Failure Exacerbation

    Etomidate doesn’t cause HF, but patients with pre-existing HF may have exacerbated underlying myocardial dysfunction after administration.

    Versed

    Versed, also called Midazolam, is the most commonly used Benzodiazepine used for sedation for RSI intubation.

    Versed also does not cause analgesia, but is a good choice for patients in status epilepticus because it offers anticonvulsant properties.

    However, it can decrease the blood pressure, so this should be avoided in patients who are hemodynamically unstable.

    Side Effects & Monitoring

    Hypotension

    Versed can cause a decrease in Mean Arterial Pressure (MAP) by 10-25%. This means Versed should generally be avoided in hypotensive patients or those at risk for hypotension (severe sepsis, trauma, etc).

    Ketamine

    Ketamine is a newer sedative used for RSI intubation. It’s structurally similar to PCP, and can cause some interesting side effects. However, it can be a great sedative and analgesic to help with rapid sequence intubation.

    The good thing about Ketamine is it preserves the respiratory drive. This makes it excellent choice for minor procedural sedation where intubation is not needed.

    However, the increased catecholamine stimulation can cause tachycardia, hypertension, and possibly increased ICP, making it a poor choice for head traumas and hypertensive crises, and also those with cardiac ischemia or aortic dissections.

    However, this can be helpful in patients who are hypotensive to increase BP or in severe asthmatics to cause bronchodilation (in theory). 

    Side Effects & Monitoring

    Laryngospasm

    Ketamine increases the risk of laryngospasm, especially in those with history of upper respiratory disease or asthma. This is because ketamine does not suppress pharyngeal and laryngeal reflexes. In this case, it can be helpful to use fentanyl with it

    Ketofol

    Ketofol is the combination of ketamine and fentanyl. This can cause analgesia, sedation, and amnesia, and can be a good choice for patients with severe bronchospasm.

    Increased Cardiac Activity

    Ketamine causes increased stimulation of the sympathetic nervous system, releasing catecholamines leading to tachycardia, hypertension, increased myocardial demand, and even possible cardiac arrhythmias.

    This can be beneficial in patients who are hypotensive, but dangerous for those with active cardiac disease or aortic dissection.

    Emergence Reactions

    Ketamine can cause an “emergence phenomenon” primarily when used for procedural sedation. This is when the patient may experience vivid and/or disturbing dreams as they wake up. Hallucinations and frank delirium may occur postoperatively up to 24 hours. 

    This usually does not happen with patients who are intubated and sedated for over 24 hours.

    Propofol

    Propofol is a common sedative, and a frequent agent of choice for maintaining sedation with a slow titratable drip. It has a characteristic appearance of milk.

    Propofol is the drug that Michael Jackson was found to have overdosed on. It causes deep sedation and does diminish the patients respiratory drive.

    Propofol has the following actions on the body:

    • Decreases airway resistance: Good for bronchospasm
    • Neuro-Inhibition: Good for intracranial pathology
    • Suppresses SNS: Good for hypertension, bad for hypotension & conditions which decrease cerebral perfusion

    Propofol IV Push?

    Make sure your specific state and facility allow RNs to give IV boluses of propofol, and if so, make sure the provider is always at the bedside. Since propofol causes deep sedation, it may not be within your scope as a nurse to push it. Seems silly, but always protect your license!

    Side Effects & Monitoring

    Hypotension

    Propofol has a blood pressure lowering effect, which can decrease the MAP by 10%, but sometimes even ≥ 30%.

    Use caution if the patient has a borderline low pressure or baseline MAP of 60-70 mmHg.

    Patients at risk for hypotension include severe sepsis, trauma, severe aortic stenosis, etc.

    Bradyarrhythmias

    Propofol can cause bradyarrythmias to occur. This is more common with high doses, prolonged duration, and concurrent medications like beta-blockers, paralytics, and opioids. Patients with a history of cardiac disease are at increased risk.

    QT Prolongation

    QT prolongation can predispose your patient to dangerous ventricular arrhythmias like Torsades de Pointes and VFIB. This is more common with:

    • High propofol doses
    • Elderly patients
    • Structural heart disease
    • Congenital Long QT
    • QT prolonging medications
    • Electrolyte Disturbances

    Anaphylaxis

    Anaphylaxis is rare with Propofol but can occur, usually within 5-10 minutes after infusion. Those with a history of soybean or egg allergy are probably fine to take it.

    Soybean Allergy

    Allergy to soybeans or egg used to be a contraindication for receiving propofol, but newer formulations of the drug rarely produce a reaction and are likely safe

    Elevated Triglycerides & Lipase

    Propofol is a lipophilic fatty solution which contains triglycerides. Infusion can lead to elevations in triglycerides and lipase, which usually occurs 2-4 days after initiation. This can lead to pancreatitis, especially in those who are already at risk.

    PRIS

    PRIS stands for Propofol Infusion Syndrome. PRIS is rare but deadly. When occurs, the patient suffers from acute refractory bradycardia which may lead to asystole, and also may have:

    • severe metabolic acidosis,
    • cardiovascular collapse,
    • rhabdomyolysis
    • hyperlipidemia
    • renal failure
    • hepatomegaly

    This is more common with high doses (>4mg/kg/hr) and long duration of use (>48 hours).

    Choosing the Right Sedative

    There are some specific scenarios where one sedative may be more appropriate than others. Regardless, it is always the Providers preference and what they’re familiar with. 

    Head Injury or Stroke

    Etomidate

    Status Epilepticus

    Propofol or Etomidate

    Severe Bronchospasm

    Propofol or Ketamine (+/- fentanyl)

    Cardiovascular Disease

    Etomidate +/- Fentanyl

    Shock

    Etomidate 0.15mg/kg or ketamine 1mg/kg

    Paralytics

    Paralytics, also called neuromuscular blocking agents (NMBAs), are given immediately after the sedative kicks in, which produces a paralyzing effect on the body. This relaxes the patients muscles and makes the intubation easier for the Physician or APP, and minimizes complications.

    Succinylcholine

    Succinylcholine or Sux for short, is the classic paralyzing agent for RSI. It is termed a “depolarizing neuromuscular blocker” because they cause the muscle cells to “fire” or depolarize, but then don’t let the muscles repolarize, leading to paralysis.

    While used in most scenarios, this is contraindicated in conditions which may cause hyperkalemia or may lead to an exaggerated response. This is because even in normal patients, Sux can increase potassium levels by 0.5-1.0 mEq/L.

    These conditions include:

    • Malignant hyperthermia (personal or family history)
    • Neuromuscular disease with denervation (i.e. MS)
    • Muscular dystrophy
    • Stroke > 72h old (especially with significant motor denervation)
    • Rhabdho
    • Significant burn(s) over 72h old
    • Significant Hyperkalemia

    Myesthenia Gravis

    Patients with MG are resistant to Sux, so should be given 2mg/kg

    Side Effects & Monitoring

    Fasciculations

    Sux commonly causes fasciculations of the muscles prior to causing full paralysis.

    This may increase ICP and stimulate emesis leading to aspiration.

    Bradycardia

    A metabolite of Sux can stimulate muscarinic receptors to release acetylcholine, producing bradycardia of the sinus node. This can be treated with atropine.

    Rocuronium

    Rocuronium or “ROC” for short is a “non-depolarizing” NMBA used for sedation for RSI intubation. This is because it is an acetylcholine antagonist, blocking its effects and leading to paralysis.

    ROC is used when Sux is contraindicated as above.

    Some conditions which may decrease the efficacy of the paralysis include:

    • Respiratory alkalosis
    • Hypercalcemia
    • Demyelinating lesions (MS)
    • Peripheral neuropathies
    • Muscle trauma

    Side Effects & Monitoring

    Hypertension

    ROC can increase peripheral vascular resistant and cause a temporary increase in BP. It can also cause transient hypotension in some people. 

    Tachycardia

    ROC can cause temporary tachycardia for about 5 minutes.

    Right-sided HF

    ROC may worsen pulmonary HTN, leading to right-sided heart failure in those who are predisposed.

    Other Paralytics

    Other non-depolarizing paralytics include Vecuronium and Pancuronium, but these are not used as often.

    Vecuronium, shortened to “VEC”, is not used as frequently, as it has a longer onset of action – around 3 minutes. This can be reduced with a smaller “priming” dose.

    The RSI Intubation Procedure

    Prepare the Patient

    To prepare the patient for RSI intubation, make sure they are positioned in the “sniffing” position, supine with their neck flexed. Placing a towel between their head and neck can help.

    Make sure the patient is getting hyper-oxygenated at the same time, usually with a Non-rebreather or a Bag-valve mask at 100%.

    Respiratory therapists are often in charge of airway along with the Provider.

    Place the patient on the monitor including telemetry, continuous pulse ox, and end-tidal CO2 if possible.

    Explain the procedure to the patient and ensure informed consent is obtained, either written or verbal. Written is often not able to be obtained due to the emergent nature of many intubations.

    If the patient is altered, ensure there is no DNR or DNI order form or POLST. 

    Using a BVM

    If using a BVM hooked up to 100% oxygen, make sure you are squeezing the BVM with each spontaneous breath to ensure the valve opens and the oxygen is given to the patient!

    Prepare the Equipment

    Bring the code cart at the bedside. You don’t necessarily need to hook up the defibrillation pads, but always follow facility protocol.

    Most of the equipment needed will be found in the Airway drawer, usually one fo the last drawers.

    The equipment needed for the actual intubation will be:

    • Laryngoscope
    • ET tube
    • Stylet
    • 10cc syringe
    • Suction Tubing & Yankauer
    • ETCO2 or CO2 detector
    • Stethoscope
    • Bag-valve mask

    Ask the Provider which size ET tube they’ll want, which is often 7.0 for females, and 8.0 for males.

    The stylet will need to be placed inside the ET tube, which is usually cuffed. This will be removed once the Provider gets the tube in the right spot.

    Administer Medications

    The Provider will give you a verbal order for which sedative(s) and paralytic they want.

    Verbally clarify the name and dose, and begin to draw up the medications. You may need to grab these medications from an “RSI kit” in the Accudose, or they may be located in your code cart.

    Usually one of the nurses will assume the “medicine” responsibility while the others are preparing the patient and equipment.

    Some medications will require reconstitution. This means you may need to mix saline with powdered medication to make a solution. Verify the final doses/amounts with another nurse.

    Make sure to accurately label each, so you don’t mix up the sedative and the paralytic!

    Once everyone is ready for the intubation, wait for the Provider’s verbal “ok” to give the medications, and administer the medications as above. Most are given quickly over 5-10 seconds. 

    First the sedative, then once the patient has decreased LOC and you get the next verbal OK from the Provider, administer the paralytic.

    RT should be bagging the patient at this time until the Provider is ready for the intubation. This is usually within 30-60 seconds after administering the paralytic.

    The Intubation

    Your main job is now done, and now you just watch the intubation procedure and monitor the patient, following any verbal orders that are given.

    The Provider will place the ET tube between the vocal cords, typically 21cm deep in women and 23cm in men. This is measured at the teeth.

    Verify Placement

    Immediately after intubation, the tube needs to be verified. This is verified in multiple ways.

    First, a CO2 detector may be attached to the ET tube. Observing color change from purple to yellow indicates CO2.

    If the patient is hooked up to an ETCO2, with each BVM breath, you should see normal CO2 levels near 35-45 mmHg.

    Additionally, someone should listen to all breath sounds listening for equal breath sounds.

    Lastly, the patient should have a portable CXR ordered to verify the placement. The radiologist may recommend pulling out or pushing deeper x amount of cm.

    Maintain Vent + Sedation

    Now the patient is successfully intubated. Your main job now is keeping the patient sedated so that the Ventilator can do its job and breath for the patient.

    This usually involves a continuous titratable drip, often propofol. The patient may also require additional sedatives, analgesics, and sometimes further paralytics.

    Of course, make sure to chart everything and continue to monitor the patient’s vital signs.

    If in the ER or Med-Surg, your goal should be to get that patient admitted/transferred ASAP.

    RSI Intubation Complications

    Unfortunately, not all RSI intubations go smoothly. These are usually emergent procedures and are not done in a controlled environment. 

    As the nurse, you are the first one who is going to notice any complications while monitoring your patient.  It’s important to know what to look out for and how these complications are managed.

    Esophageal Intubation

    This is when the ET tube is in the esophagus instead of the trachea. This becomes obvious when verifying placement.

    When it occurs, the ET tube will be completely removed and the Provider will re-insert the tube with another attempt.

    Gastric Tube

    An OG or NG to suction should be placed in all patients after intubation to decompress the stomach to prevent emesis and to decrease intrathoracic pressure.

    A foley should also be placed.

    Right Mainstem Intubation

    If the ET tube is placed slightly too deep, it will often go into the Right Mainstem Bronchus of the right lung. This is because it is more vertical than the left.

    If left, the patient may have signs of hypoxemia and worsening respiratory status, and if not fixed can cause barotrauma, pneumothorax, and hemothorax.

    Breath sounds should be equal throughout the lobes, but a CXR will need to be done to verify this isn’t the case. 

    Treatment involves pulling out the ET tube per radiologists recommendations, which the Provider should do.

    Perforation

    A traumatic insertion can cause perforation of the esophagus or trachea. This is very rare, but severe.

    Signs include presence of subcutaneous emphysema in the mediastinum, and worsening respiratory status.

    A CXR may show pneumomediastinum, subcutaneous emphysema, and possible pneumothorax.

    RSI Intubation is common in the ER and ICU, but can still be nerve-wracking and should cause an adrenaline rush! Equipping yourself with knowledge and familiarity is the best thing you can do to become comfortable during this procedure!

    REFERENCES

    Bookatz A., & Sakles, J. C. (2021). Rapid sequence intubation. In B. Simpson (Ed.), Wikem.org. https://wikem.org/wiki/Rapid_sequence_intubation

    Brown, C. A., & Sakles, J. C. (2022). Rapid sequence intubation for adults outside the operating room. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/rapid-sequence-intubation-for-adults-outside-the-operating-room

    Caro, D. (2022). Induction agents for rapid sequence intubation in adults outside the operating room. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adults-outside-the-operating-room

    Caro, D. (2022). Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/neuromuscular-blocking-agents-nmbas-for-rapid-sequence-intubation-in-adults-outside-of-the-operating-room

    Morgan, M. A. (n.d.). Esophageal intubation. In Radiopaediahttps://radiopaedia.org/articles/oesophageal-intubation

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      Oxygen Delivery Devices and Flow Rates

      Oxygen Delivery Devices and Flow Rates

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      William J. Kelly, MSN, FNP-C
      William J. Kelly, MSN, FNP-C

      Author | Nurse Practitioner

      Oxygen Delivery Devices and Flow Rates are important concepts to understand as a nurse. Oxygen is a life-saving therapy that nurses and respiratory therapists administer every day in the hospital.

      Whether your patient is on chronic oxygen, or whether they are in acute respiratory failure, your patients will commonly have oxygen ordered and it will be up to you as the nurse to administer it. 

      Knowing the oxygen delivery devices and flow rates will tremendously help you take care of your patients who requires oxygen.

      Oxygen delivery devices and flow rates FB

      The Role of Oxygen

      Oxygen is used every day in and out of the hospital. In order to understand oxygen delivery devices and flow rates, we need to first understand a few basic principles and definitions.

      Oxygen is the most important gas in our atmosphere that allows for humans and animals to live. Our cells use oxygen to create energy (Kreb’s cycle anyone?). Our ability to create energy without oxygen is very limited.

      Without oxygen, our cells will die within minutes.

      Oxygen occurs naturally in our atmosphere, at a concentration of 21%. Another term for oxygen concentration is FIO2, or fraction of inspired oxygen.

      When we breathe in air, the air (including oxygen) enters into our lungs and makes contact with all of the alveoli. Alveoli are small sac-like structures within the lungs.

      The oxygen diffuses across these alveoli into the bloodstream, where it attaches to hemoglobin on our red blood cells. Our blood carries this oxygen throughout the body where it is absorbed by the tissue to give life and energy to our cells.

      A healthy patient has a respiratory rate of 12-20 respirations per minute (rpm). Lower than 12 is usually from medications like opioids or benzos, and higher is usually from anxiety, asthma, COPD, CHF, a PE, pneumonia, or some other type of respiratory failure.

      The tidal volume is the amount of air breathed into the lungs with each breath. The tidal volume will depend on the patient’s physical size of their lungs and their respiratory effort, but is generally around 400-500ml in a healthy adult.

      The FIO2 or the fraction of inspired oxygen is the percentage or concentration of oxygen that a person inhales. Remember room air is always at 21% FIO2 on earth.

      Oxygen Delivery Devices and Flow Rates

      There are different oxygen delivery devices and flow rates to know, with each device allowing for certain flow rates of oxygen (L/min), as well as different concentrations of oxygen (FIO2).

      Blow-by Oxygen

      Blow-by oxygen is just that – it’s oxygen that blows by. This does not not apply oxygen directly, but rather indirectly by “blowing” on the patient’s face.

      This is usually only used in infants and young toddlers who become agitated when masks or tubing is applied.

      Less than 30% FIO2 can be provided with this, which is not much greater than room air of 21%.

      If used, the oxygen rate should be at least 10 L/min through a simple mask or even a tubing sticking through a styrofoam cup, which infants and toddlers may be less scared of.

      Nasal Cannula

      Nasal cannula is tubing that runs from the oxygen source to the patient’s bilateral nares or nostrils.

      This is the most common use of oxygen within the hospital, especially for non-critical patients and those who need chronic oxygen delivery like with COPD.

      Nasal Cannula is typically started at 2L/min and then titrated upwards to as high as 6L/min, although 2-4L/min is ideal. This delivers 25-40% FIO2, depending upon their respiratory rate, tidal volume, and amount of mouth breathing.

      The nasal cannula is good for most patient needs with lower levels of oxygen requirements.

      Nasal cannula can be very irritating and cause dry nares at rates >2L/min, so the oxygen should be heated and humidified if possible at higher flow rates.

      Simple Face Mask

      Simple face masks are a mask with tubing that is hooked up directly to an oxygen source. This is similar to Nasal Cannula, except it is delivered in a mask format over the mouth and the nose, instead of just the nose.

      Simple face masks allow for flow rates between 6-10L/min, with an FIO2 of 35-50%.

      Simple face masks tend to be a temporary solution, used when titrating your oxygen delivery devices and flow rates. 

      Ventimask

      Ventimask or a Venturi mask is a face mask that is connected to corrugated tubing with a venturi valve on the end.

      This piece connects to the oxygen tubing, which mixes oxygen with room air to provide a consistent high flow of oxygen even with irregular respiratory rates or tidal volumes.

      Depending on the oxygen flow rate, there are different colored venturi pieces that are used, with FIO2 of 24-60% FIO2 depending on which venturi valve is used. Levels >40% are generally not used and likely don’t offer more benefit.

      The oxygen flow rate will be indicated on the specific venturi valve used, but generally is from 3-10L/min.

      Some Ventimasks come in an all-in-one rotational setup, where the FIO2 can be adjusted on a single venturi valve.

      Ventimasks are usually used with COPD patients when they require high levels of oxygen, but there is concern for CO2 retention. It can also be helpful for asthma exacerbations and general respiratory distress.

      This is typically not used long-term.

      Non-Rebreather

      A Non-rebreather is typically what is initially used when the patient is requiring a high flow of oxygen and nasal cannula’s are not cutting it.

      A non-rebreather provides the highest concentration of oxygen that can be provided to a patient who is breathing on their own, up to 95% FIO2, without any additional machines.

      However, this is NOT a long-term solution, and unless they can be titrated down, patients will need to be transitioned to a BIPAP, HFNC, or intubation, unless they can be titrated down.

      In a non-rebreather, there is a reservoir bag attached to the mask, with a one-way valve separating the two. This prevents exhaled CO2 from entering the reservoir, and only allows oxygen.

      There are holes or “exhalation ports” in the sides of the mask that allow expired are out also do not allow room air back in (usually only one of these is “blocked” to prevent suffocation if the oxygen turns off).

      Oxygen flow rates of 10-15L/min can deliver FIO2 of up to 95% in these individuals. However, there is a small amount of room air which “gets in” the system, so the FIO2 is invariably lower, more like 80-90%.

      Remember over-oxygenation can also be dangerous termed “oxygen toxicity”. This can cause vasoconstriction, worsen outcomes, and even cause seizures.

      This means you want to keep the patient’s SPO2 at 94-99%, as a pulse ox does not measure above 100%.

      If a patient is still struggling to breathe with SPO2 of 88-94% or lower on a NRB, then they probably need intubated.

      High-Flow Nasal Cannula

      High-Flow Nasal Cannula (HFNC) is a newer method of delivering a high flow and FIO2 of oxygen in patients who have higher oxygen requirements. COVID patients tend to do well on these devices, but it can be used for all sorts of respiratory distress.

      High-flow Nasal cannula consists of a specific machine and tubing used to deliver a very high flow of oxygen that is heated and humidified.

      HFNC can be delivered from 8-60L/min (30-60 L/min in adults), and an FIO2 of 100%.

      HFNC is more comfortable and studies have shown that using HFNC may be a better alternative than using a face mask.

      HFNC also adds PEEP-like pressure equivalent to about 3-4 cm H2O, similar to a CPAP, helping to keep the alveoli open and increase ventilation (gas exchange).

      It is also an alternative to BIPAP other than those patients who are hypercarbic (high CO2 levels like in COPD).

      Knowing the difference between the oxygen delivery devices and flow rates, HFNC is not a good option for those who are CO2 retainers for very long .

      CPAP

      CPAP or Continuous Positive Airway Pressure is a method of non-invasive ventilation. This helps open up the alveoli allowing for better gas exchange.

      This can be useful in acute pulmonary edema like in CHF, because it reduces intrathoracic pressure and can reduce preload and increase cardiac output, as well as decrease alveolar congestion.

      It is also used for obstructive sleep apnea (OSA) to keep the airway open.

      Oxygen is not always added (especially if the patient is just using it for OSA). The pressure is set at 5-20 cm H2O, usually beginning at 5-8 cm H2O.

      Increased pressures will increase intrathoracic pressures.

      Oxygen is added to keep SPO2 >90%.

      BIPAP

      BIPAP or Bilevel Positive Airway Pressure is the “better” version of CPAP. This can often be used as an alternative to intubation, and is great for hypercapnic respiratory failure (think COPD).

      This uses a higher pressure during inspiration and a lower pressure during expiration.

      BIPAP uses 3 settings:

      • Rate: The respiratory rate is usually set to a backup or spontaneous rate, as these patients are awake and breathing spontaneously. This is usually 8-12 rpm. Most patients on a BIPAP will be breathing much faster than this.
      • IPAP: The inspiratory positive airway pressure is how much pressure is given during inspiration. This is anywhere from 5-30 cm H2O, but usually started at 8-12 cm H2O. A higher level will increase tidal volume.
      • EPAP: The expiratory positive airway pressure is the pressure during expiration, which is typically 3-5 cm H2O.

      Oxygen delivery is then used as well to ensure SPO2 >90%. FIO2 is started at 100% and titrated down.

      Clinical Note: Settings are usually given as IPAP/EPAP, Rate, and FIO2. This means you would relay the settings as 10/5, backup rate of 10, and an FIO2 of 30%. The RT should tell you the settings and they should be the ones to titrate the FIO2.

      This is used for Acute COPD exacerbations, and acute respiratory failures like in CHF or ARDS. It can work great for reducing CO2 retention in hypercarbia subsequent and respiratory acidosis.

      This is not good for those who are nauseous or have thick secretions, as this may be a risk for aspiration. This can be dangerous for those who are altered for the same reason, although is sometimes still used.

      Ventilator

      Mechanical Ventilation is the best way of controlling a patient’s oxygenation (oxygen delivery) and ventilation (gas exchange).

      Mechanical ventilation is used as a last resort when a patient is in severe respiratory distress and cannot tolerate non-invasive ventilation.

      These patients are in respiratory failure and may be altered, cannot protect their airways, are throwing up, or just continue to be hypoxic despite alternative oxygenation.

      To be put on a ventilator, a patient will need intubated, likely sedated, and hooked up to a ventilator.

      Ventilators have various settings which control the respiratory rate, the IPAP, the EPAP, the inspiratory flow rate, and the FIO2%.

      If ventilation can be avoided, it should be. Some patients are difficult to wean off the vent (like in severe COPD or ARDS).

      And that is an overview of oxygen delivery devices and flow rates. Hopefully you have a solid understanding of each device and when it is appropriate to use each one.

      References

      Hyzy, R. C., & McSparron, J. I. (2021). Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/noninvasive-ventilation-in-adults-with-acute-respiratory-failure-practical-aspects-of-initiation

      ICU Advantage. (2020, January 13). CPAP vs BiPAP – Non-Invasive Ventilation EXPLAINED [Video]. YouTube. https://www.youtube.com/watch?v=Te0WLR71HwA

      Nagler, J. (2021). Continuous oxygen delivery systems for the acute care of infants, children, and adults. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/continuous-oxygen-delivery-systems-for-the-acute-care-of-infants-children-and-adults

      Need to Level Up Your ECG Rhythm Game?

      If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.

      With this course you will be able to:

      • Identify all cardiac rhythms inside and out
      • Understand the pathophysiology of why and how arrhythmias occur
      • Learn how to manage arrhythmias like an expert nurse
      • Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

      I also include some great free bonuses with the course, including:

      • ECG Rhythm Guide eBook (190 pages!)
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      Check out more about the course here!

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      Adverse Drug Reactions Nurses NEED to know

      Adverse Drug Reactions Nurses NEED to know

      [social_warfare]

      Medications are a huge part of modern medicine and how we treat disease, but there are many adverse drug reactions that can occur.

      As nurses, it is important to educate our patients about these adverse drug reactions, what to expect, and what to do if they are experienced by our patients.

      Some of these medication reactions are ingrained in us, but others are less commonly taught.

      Make sure you remember to educate your patients who are being prescribed these medications!

      adverse drug reaction - featured image

      Antibiotics and Adverse Drug Reactions

      Antibiotics are essential in treating bacterial disease, but they don’t come without their own side effects!

      There are many different classes of antibiotics. Because of this, some adverse drug reactions apply to only certain antibiotics, and some apply to antibiotics as a whole.

      1. Diarrhea and Antibiotics

      All antibiotics can cause diarrhea. This is due to normal “good” bacteria in your intestines being killed by the antibiotic, leading to imbalances digestion.

      While all antibiotics can cause diarrhea, there are certain antibiotics that are more likely to cause diarrhea.

      These include amoxicillin, cephalosporins, clindamycin. When mixed with clavulanic acid, diarrhea tends to be more pronounced (i.e. Augmentin).

      Clostridium Difficicile (CDIFF) is an opportunistic diarrheal infection that can lead to profuse diarrhea and can be difficult to treat.

      Antibiotics increase the risk of CDIFF – especially broad-spectrum antibiotics like cephalosporins, fluoroquinolones, and clindamycin.

      Patient Education Example: “Some watery diarrhea and mild cramping can be expected while on antibiotics. Make sure to stay hydrated if this occurs. If you have excessive diarrhea, severe abdominal pain, abdominal swelling, fever, or blood or pus in your diarrhea – you should contact your doctor or return to the emergency department”. 

      adverse Drug Reactions - Abx and diarrhea

      2. Allergic Reactions

      All medications and antibiotics can cause allergic reactions.

      True allergic reactions cause itchy hives and potentially swelling of the face, eyes, lips, or mouth. It can even cause swelling of the airways and lead to wheezing and stridor.

      When giving any prescribed medications, the patient should always be educated on the potential signs of an allergic reaction.

      Patient Education Example: “All new medications can cause allergic reactions, and mild-moderate allergic reactions are common with antibiotics. If you develop a red, raised, itchy rash, immediately stop taking the antibiotic and call your doctor. If you develop swelling of the face, eyes, lips, tongue, or shortness of breath – this is potentially a life-threatening severe allergic reaction called anaphylaxis, and you should seek immediate medical care or call 911.”

      Adverse Drug Reaction - Allergic

      3. Rifampin and Birth Control

      Antibiotics were frequently thought to interact with birth control… but this is somewhat of a myth.

      There is no convincing evidence that any antibiotic other than Rifampin interacts with birth control.

      Rifampin is not a commonly prescribed antibiotic but is the recommended treatment for tuberculosis.

      There is a concern that antibiotics as a whole can affect the gut microbiome which may alter estrogen levels, but this has not been proven and is likely untrue.

      If patients are prescribed rifampin, they should be educated to use backup protection for up to 1 month after they finish the rifampin.

      Patient Education Example: “While commonly believed to interact with birth control, there’s no evidence that most antibiotics do. If you want to be safe, you can use a backup method like condoms while taking the antibiotic, and up to a few days to a month after you finish.”

      Adverse Drug Reaction - Rifampin and OCP

      4. Doxycycline and GI Upset

      Doxycycline is commonly given for infections including cellulitis, URIs, tick-borne illnesses, pneumonia, STDS, and more.

      Doxycycline works great, but it does have some significant adverse drug reactions that we need to educate our patients about.

      Doxycycline can cause some significant GI upset, including nausea, vomiting, and diarrhea.

      Educating the patient to take this pill with food or milk can help, although it may inhibit some absorption of the drug.

      Doxycycline (and clindamycin) can cause drug-induced esophagitis which can lead to significant inflammation and pain within the esophagus.

      To prevent this, educate the patient to take Doxycycline with a full glass of water, milk, or eat food afterward, and stay upright for 30 minutes after taking it.

      Patient Education Example: “Doxycycline can cause significant nausea and vomiting, and drinking milk or eating food directly after taking it can help minimize this. If not, drink with a full glass of water and remain upright for 30 minutes afterwards to prevent any damage to your esophagus.”

      Adverse Drug Reaction - Doxycyline pill esophagitis

      5. Flagyl and ETOH

      Metronidazole, or Flagyl, or is commonly given for intestinal infections like colitis or diverticulitis, and for vaginal infections like trichomoniasis.

      Flagyl is traditionally taught to NEVER be taken with alcohol as this can cause a “disulfiram-like reaction”.

      Flagyl + ETOHDisulfiram causes excessive nausea, vomiting, and other unpleasant symptoms when mixed with alcohol.

      Evidence of this severe reaction occurring with Flagyl is somewhat lacking, but it can sometimes occur. Educate the patient on this potential reaction, but if they do drink they may be fine.

      It is never a bad idea to recommend against taking medications with alcohol.

      Patient Education Example: “Flagyl can potentially cause nausea and vomiting if taken with alcohol. Avoid any alcohol consumption while taking it”. 

      6. Fluoroquinolones and Tendon Rupture

      Fluoroquinolones are a powerful class of antibiotic which kill a broad-spectrum of bacteria.

      These are commonly utilized to treat UTIs, Abdominal infections, and Pneumonia.

      Fluoroquinolones have fallen out of favor recently due to their large number of potential side effects, even if rare.

      These side effects include:

      • Hyper/hypoglycemia
      • Peripheral neuropathy
      • CNS effects (seizures, increased ICP, tremors)
      • Psych reactions (psychosis, hallucinations, deririum, etc)
      • Aortic aneurysm and dissection
      • Tendonitis and tendon rupture.

      Sometimes these antibiotics are still needed, so be sure to educate the patient on these possible side effects.

      The tendinopathy can occur hours or days after starting the antibiotic or sometimes delayed for months.

      This is more likely to occur in those >60 years old, those on steroids, with diabetes or kidney failure, or with extended therapy.

      Patient Education Example: “Cipro can rarely cause significant side effects like inflammation and even rupture of your tendons, most commonly the Achilles tendon above your heel. If you feel any swelling or pain in this area or near another joint, immediately stop taking and contact your doctor”.

      Adverse Drug Reaction - Tendon rupture

      Non-Antibiotics and Adverse Drug Reactions

      Antibiotics are not the only cause for adverse drug reactions, and every medication has expected side effects.

      While there are many potential adverse effects for every single medication, there are a few common or interesting side effects you should know to educate your patients on!

      7. Dexamethasone and the Burning Crusade

      Dexamethasone is a steroid given for various reasons, including sore throats, cerebral edema, migraines, and various other conditions in and out of the hospital.

      Dexamethasone is commonly ordered IV in the ED and hospital. One interesting side effect that you need to warn your patients about perineal discomfort when given IV.

      When given rapidly, perineal discomfort (burning or tingling) can occur.

      I’ve personally heard “MY CROTCH IS ON FIRE!”.

      This is usually short-lived but can cause significant discomfort and be shocking for the patient if not warned.

      Dilute the dexamethasone in NS and infuse over 15-30 minutes to help minimize this side effect.

      Patient Education Example: “I’m going to give you some IV Dexamethasone to help with your condition. Sometimes it can cause brief burning or discomfort in your groin, but we are giving it slowly to try and prevent that. It can still happen though, so if it does I just want you to be aware.” 

      Related Content: 

      8. Adverse Drug Reactions with Opioids

      Opioids like Oxycodone or Hydrocodone are commonly given for pain and can be a great tool we can use to offer relief to our patients.

      Unfortunately, opioids do have significant side effects that need to be taught to our patients.

      Opioids cause respiratory depression and this is how opioid overdoses kill people.

      But appropriate doses, it shouldn’t cause significant respiratory depression unless mixed with other medications or alcohol.

      Opioids also cause drowsiness and even stupor, so anything that requires a high level of mental alertness needs to be avoided.

      This includes driving or operating heavy machinery.

      Patient Education Example: “Oxycodone helps your pain but can cause drowsiness, so you shouldn’t drive or operate any heavy machinery. It can increase your risk of falls, so be careful on the stairs. You should never take this medication with alcohol, other opiates, or benzodiazepines like Xanax or Ativan.”

      Related Content: Opioid Alternative Analgesics in the ER

      9. Anticoagulants and Bleeding

      Adverse Drug Reaction - Brain bleedAnticoagulants are often necessary to prevent blood clots in those with a history of DVT, PE, or Atrial Fibrillation.

      Unfortunately, they also hinder the body’s natural ability to clot when injured.

      This can lead to ineffective clotting and an increased risk of bleeding. Patients on blood thinners should take extra precautions to prevent trauma like falls.

      If there is a head injury, these patients should be evaluated by a medical professional, preferably within the ED where a CT scan can be obtained to rule out an intracranial bleed.

      Patient Education Example: “Eliquis helps prevent blood clots, but it also increases your chance of bleeding. If you fall or sustain any injury, you should be evaluated by a doctor. If you hit your head, you should call your doctor or come to the ER.”

      Every medication has adverse drug reactions, but we should be knowledgeable about these common or potentially serious reactions, and educate our patients!

      Is there any other drug reaction that you are sure to educate your patients about? Let us know in the comments!

      [simple-author-box]

      adverse drug reaction - Pin

      Intravenous Fluids: Types of IV fluids

      Intravenous Fluids: Types of IV fluids

      William J. Kelly, MSN, FNP-C
      William J. Kelly, MSN, FNP-C

      Author | Nurse Practitioner

      Intravenous fluids are commonly used in hospitals and emergency departments. There are many different types of IV fluids, which are used both as IV boluses as well as maintenance fluids. Understanding the difference between the types of IV fluids can be challenging, but as a nurse, it is important to understand.

      Intravenous fluids featured image

      Indications for Intravenous Fluids

      Intravenous fluids are very commonly used in healthcare settings. Most frequently, IV fluids are used to hydrate those with dehydration. Additionally, they can be used to support blood pressure in those with hypotension or sepsis.

      IV fluids can also be used as maintenance fluids for those who are not able to intake enough hydration throughout the day.

      In the ER, I commonly order Intravenous fluid to those with nausea and vomiting, diarrhea, dehydration, acute kidney injury, abdominal pain, headaches, bleeding, or infections.

      Maintenance Fluids vs IV Bolus

      Maintenance fluids are intravenous fluids that are run at a slower rate, usually to account for decreased PO intake or expected fluid losses. Patients who are NPO (nothing by mouth) are commonly ordered maintenance fluids, as well as those with ongoing fluid losses.

      Maintenance Fluids

      Ongoing fluid losses commonly occur with various medical conditions. Fevers commonly require increased maintenance fluid, as they cause “insensible water losses” from sweating and overall increased metabolism.

      Those experiencing frequent vomiting or diarrhea require increased fluid to account for their ongoing water losses in their vomit or stool. The same goes for those with drains experiencing significant drainage.

      Those with burns or pancreatitis often require a large volume of fluids.

      Those admitted with dehydration, mild hyponatremia, or acute renal failure will usually require maintenance fluids in order to slowly correct their hydration, sodium levels, and renal function.

      When a patient is NPO, maintenance fluids keep the patient hydrated. To calculate maintenance fluids when a patient is NPO, you can take the patient’s body weight in Kilograms, and use the following equation: (Kg – 20) + 60 = mL/hr. (Ref).

      Please note that this is not a hard rule. Those with ongoing fluid losses and various medical conditions may require a faster rate, and those who are older or with CHF may require slower rates.

      Clinical Note: Just because a patient is NPO after midnight does not mean that they need maintenance fluids ordered. Do you usually drink water in the middle of the night while you sleep?

      IV Bolus

      IV boluses are intravenous fluids given rapidly over a short amount of time. This is most frequently used within acute care settings such as the ER or the ICU in those who are unstable with low blood pressure. Giving an IV bolus helps support blood pressure and correct hypotension.

      It is common for a 1 liter IV bolus to be ordered on patients initially presenting to the ER, as fluids can help many different conditions. You will commonly see between 1-3 Liters of IV boluses, for conditions such as dehydration, sepsis, shock, migraines, abdominal pain, and n/v/d.

      In sepsis, 30ml/kg boluses are commonly ordered. If a bolus is ordered, hang the bolus (usually 1L bags) by gravity and open the clamp wide open. Make sure the patient keeps their arm straight if the IV is in the AC, otherwise the bolus won’t flow.

      Clinical Note: If using a pump, run the fluid at 999ml/hr. Please note that in true emergencies this may not be fast enough, and using gravity and/or a pressure bag will infuse the fluid more quickly.

      Important Fluid Concepts to Understand

      Before diving into the different types of IV fluids, there are a few important underlying concepts we need to understand.

      Tonicity, Osmolarity, and Osmosis

      Tonicity refers to a fluid’s ability to move fluid into or out of cells and is related to osmolarity – which is the total concentration of solutes within a solution. The more solutes, the higher the osmolarity.

      In the body, water shifts into or out of our cell through a semi-permeable membrane – the cell wall. This means water freely flows through it, but larger solutes do not such as our electrolytes (sodium, chloride, potassium, etc).

      Osmosis occurs, which is when water flows from a higher osmolarity to a lower osmolarity to “balance” out the concentrations of each side, in this case inside and outside of the cell.

      Isotonic, Hypotonic, and Hypertonic Fluids

      Isotonic fluids are IV fluids that have nearly the same osmolarity as intracellular fluid. This means that this IV fluid should not cause any significant net fluid shifts into or out of cells.

      Hypotonic fluids are IV fluids that have a lower osmolarity than inside the cells, which causes net fluid shifts into the cells. This leads to cellular swelling, which can be deadly in certain conditions like severe head injuries and increased Intracranial Pressure (ICP).

      Hypertonic fluids are IV fluids that have a higher osmolarity than inside the cells, which causes net fluid to shift out of the cells. This leads to cellular dehydration and shrinking.

      Types of IV Fluids

      There are many different types of IV fluids that can be ordered, and knowing the difference between them is important. Certain intravenous fluids are useful for certain situations, and others can be harmful.

      As a nurse, it is important to know the basics. As a nurse practitioner, you will be responsible for ordering these fluids so this becomes even more necessary to understand.

      Normal Saline (0.9% NS)

      Normal Saline, NS, or NSS is the standard fluid given in both boluses and as maintenance fluids. Normal saline contains sodium chloride (NaCl) and is isotonic. This means when given through the IV, there should be no net movement of fluid or electrolyte into or out of the cells.

      This ensures that there is no unnecessary swelling or shrinking of the cells when infused. Normal saline is the cornerstone intravenous fluid because it can be given for most situations, including:

      • Hydration
      • Maintenance Fluids
      • Hyponatremia
      • Hypotension or Shock
      • Sepsis
      • with Blood transfusions

      Normal saline is cheap and does not result in allergic reactions, and almost all medications are compatible.

      Use caution with heart failure or end-stage renal disease, and those on dialysis or in acute fluid overload should probably not receive IV fluids.

      A large amount of Normal Saline (3-5+ liters) can cause significant hyperchloremic non-anion gap metabolic acidosis, especially if the patient has renal failure. This can worsen their outcomes within the hospital.

      As with any IV fluid, continually monitor fluid status by making sure the patient is not having worsened lower extremity edema or new rales/crackles in the lungs.

      If the patient develops sudden shortness of breath during IV fluid administration, consider fluid overload and flash pulmonary edema as a potential cause, especially with a history of heart failure.

      You should always be assessing for IV infiltration as well. If there is significant swelling, blanching, and coolness near the IV site – you probably need to remove it and start a new IV.

      Related articles:

      Lactated Ringers (LR)

      Lactated Ringers (LR) is another isotonic fluid that is commonly given. LR is the fluid of choice by surgeons, and some consider LR to be slightly better than NS, but the general consensus is that ‘One is not better than the other’.

      Lactated Ringers differ from NS in that it not only has sodium chloride, but also has sodium lactate, potassium chloride, and calcium chloride.

      So why choose LR over NS? LR is buffered and won’t cause the hyperchloremic metabolic acidosis that large volumes of NS can. Some studies showed improvement in renal function in critically ill patients who were on LR as opposed to NS, but the evidence is mixed.

      LR can be given for all of the indications that NS can be given, including:

      • Dehydration
      • Maintenance Fluids when NPO
      • Ongoing fluid losses
      • Sepsis
      • Allergic Reactions

      LR is preferred over NS in certain situations, including:

      • Pancreatitis
      • Burns
      • Surgical patients (surgeon preference)
      • Sepsis

      LR should be avoided in:

      • Severe liver or renal failure
      • Metabolic alkalosis > 7.5
      • Hyperkalemia or Hypercalcemia
      • Blood transfusions (If run in the same line can cause precipitation)

      As with any fluid administration, be on the lookout for fluid overload as well as local site reactions including infiltration or phlebitis.

      Side Note: LR contains sodium lactate, not lactic acid. However, giving LR during sepsis can mildly influence the lactic acid level (about .9 mmol/dL), but this does not actually worsen the sepsis, and has actually giving LR has been shown to indicate lower mortality overall. Interestingly enough, NS also seems to elevate Lactic levels within in the blood. 

      Intravenous Fluids IVF - Isotonic fluids

      Half Normal Saline (0.45% NS)

      Half normal saline (.45% NS) has half the tonicity of Normal saline. This means Half-NS is hypotonic, so the IV fluid has a lower osmolarity than the fluid inside the cells.

      This means that half normal saline will cause fluid to shift inside the cells, causing the cells to swell. This can be good in certain situations, and very bad in others.

      Half-Normal Saline is rarely given alone, but usually in combination with Potassium or dextrose. However, you may see slower rates given in conditions which cause significant cellular dehydration, such as with:

      • Hypernatremia
      • Severe DKA

      Half-Normal saline, when run alone, is typically the wrong choice for most other scenarios as it can deplete intravascular volume and cause cellular edema. Hypotonic fluids are especially bad when it comes to:

      • Head injuries or increased ICP
      • Trauma
      • Burns
      • Liver disease

      When given, make sure the patient’s sodium levels are monitored daily, as this can cause hyponatremia.

      Intravenous Fluids IVF - Hypotonic fluids

      Hypertonic Saline (3% NS)

      Hypertonic saline is given with severe hyponatremia or with increased intracranial pressures.

      Hypertonic saline is carefully and selectively given, as correcting sodium too quickly can lead to osmotic demyelination syndrome, causing irreversible neural damage.

      If a patient has severe hyponatremia and symptoms consistent with cerebral edema, then hypertonic saline should be administered. These symptoms include:

      • Seizures
      • Severe headaches
      • Decreased LOC
      • Tremors

      The dose is usually a 100mL bolus given over 10 minutes (a rate of 600ml/hr), which can be repeated twice if needed.

      Additionally, hypertonic saline can be given in the setting of severe head injury to reduce intracranial pressure.

      If your patient is ordered hypertonic saline, this needs to be on a pump, and the patient needs to be hooked up to the monitor and have frequent neuro checks. Seizure precautions should also be taken if severe hyponatremia is present.

      Related article: “The Cranial Nerve Assessment for Nurses”

      Hypertonic Fluids

      Dextrose-Containing Solutions

      Dextrose can be added to any of the fluids mentioned above, as well as to water. Dextrose solution is usually ordered for:

      • Hypoglycemia
      • Maintenance fluids

      Dextrose is osmotically active, meaning it does cause the fluid to increase its tonicity, and will lead to net fluid shifts out of the cells. However, dextrose is rapidly metabolized, so the effective osmolarity tends to be higher than the base fluid, but lower than the calculated osmolarity.

      Common dextrose solutions include:

      • D5W: Dextrose 5% in Water
      • D10W: Dextrose 10% in Water
      • D5NS: Dextrose 5% in NS
      • D5 1/2 NS: Dextrose 5% in 1/2 NS
      • D5LR: Dextrose 5% in LR

      Overall, there is little evidence that dextrose with NS has any benefit or harm when compared to saline alone. However, dextrose should probably be added in:

      • Hypoglycemia
      • Alcohol intoxication
      • Starvation ketosis

      Dextrose should not be used in:

      • Hyperglycemia
      • Hypokalemia

      An amp (25gm) of 50% Dextrose (D50) is often given as an IV push medication to treat profound hypoglycemia or in conjunction with IV insulin to lower potassium levels.

      D5W and D10W are often used for slow correction of chronic hypernatremia, or when hyponatremia has been too-rapidly corrected. It is often commonly found mixed with certain medications.

      A patient on dextrose-solution should have their blood sugar monitored, as well as their electrolytes as with any IV fluid. Dextrose-containing solutions should not be given in boluses unless as described above with D50.

      Potassium-containing Solutions

      Sometimes potassium may be added to each liter bag of fluids. Potassium may be added to maintenance fluid in:

      • Hypokalemia
      • Ongoing potassium losses
      • DKA or severe hyperglycemia

      Potassium is as osmotically active as sodium, so this will increase the osmolarity and cause the fluid to be more hypertonic.

      This means that adding potassium to an isotonic fluid will make it hypertonic, so may not be a good choice in those with cellular dehydration like in DKA.

      In these instances, adding potassium to a hypotonic base fluid such as D5NS with potassium is a great alternative option.

      Remember that potassium should NEVER be used as a bolus. IV administration should not exceed 10mEq/hour in most situations, or 20mEq/hour in critical situations with cardiac monitoring and preferably a central line.

      Related Article: “9 Nursing Medication Errors that KILL”

      Bicarbonate-containing Solutions

      Sometimes Bicarb can be added to IV fluids, in order to assist with significant metabolic acidosis. This is not super common outside of the ICU.


      And that sums up IV fluids! Hopefully you found this article helpful. If you have any unanswered questions, please comment down below!

      References:

      Rochwerg, B. et al (2014). Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Annals of internal medicine161(5), 347–355. https://pubmed.ncbi.nlm.nih.gov/25047428/

      Sterns, R. H. (2020). Maintenance and replacement fluid therapy in adults. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/maintenance-and-replacement-fluid-therapy-in-adults

      Wilkins, L. W. (2005). Fluids and electrolytes made incredibly easy. Lippincott Williams & Wilkins.

      Zitek, T., Skaggs, Z. D., Rahbar, A., Patel, J., & Khan, M. (2018). Does Intravenous Lactated Ringer’s Solution Raise Serum Lactate?. The Journal of emergency medicine55(3), 313–318. https://pubmed.ncbi.nlm.nih.gov/25047428/

      Intravenous fluids Pinterest pin

      Opioid Alternative Analgesics in the ER

      Opioid Alternative Analgesics in the ER

      [social_warfare]

      Opioids are necessary in medicine – they provide essential pain relief for those experiencing both acute and chronic pain. From kidney stones to chronic back pain, opioids are often necessary to increase quality of life for those suffering from debilitating pain. However, opioid alternative analgesics should not be ignored, and there are often many valid reasons for starting with these non-opioid analgesics first, or even using them as adjuncts to minimize side effects and provide better overall relief.

      Why even consider opioid alternative analgesics in the first place?

      It’s no surprise to anyone working in healthcare that there are indeed those people who are classified as “drug seekers”, lying to medical providers so they can continue to score narcotics. Regardless, nurses and Providers should still provide pain relief as best they can without bias or judgment. We can only do our best to provide the best pain relief while still being cognizant of the potential for those to take advantage. However, healthcare workers should consider opioid alternatives in many more individuals than just potential “drug-seekers”.

      Opioids can provide great pain relief but also come with quite a few side effects. These include nausea and vomiting, sedation, respiratory depression, and even hypotension. These side effects tend to be more profound in the elderly, and delirium or confusion is common within the hospital. For chronic opioids, constipation can be a troublesome adverse effect. Oftentimes opioids may still be necessary, especially in acute conditions, but limiting the dose and frequency while supplementing non-opioid analgesics is a great way to reduce side effects while still providing adequate pain relief.

      OFIRMEV (IV TYLENOL)

      Ofirmev, or Acetaminophen, is your standard Tylenol but in IV form. Tylenol is one of the safest pain medications you can take – as long as you don’t overdose (trust me – Tylenol overdoses are NOT pretty). While Tylenol pills work decently, IV Tylenol anecdotally seems to work great for some people. The IV route ensures rapid action and onset of pain control. However, studies seem to be mixed on whether or not IV Tylenol provides superior pain control to PO Tylenol, and this systematic review suggests no clear indication for prescribing IV over PO – at least when the patient is able to tolerate oral. But even oral Tylenol is also a valid opioid alternative and has been shown to be effective for many types of pain – especially as an adjunct.

      Ofirmev does not have a generic brand as of yet, so it tends to be expensive. However, this is cheaper than it used to be. The cost of 1gm of Ofirmev (standard dose) is $57, while 1gm of PO Acetaminophen is less than $1 – so cost is still something to consider. For repeated dosing, if the patient can tolerate PO Tylenol – you should probably try that (or risk getting yelled at by your hospital pharmacist).

      KETOROLAC (IV/IM TORADOL)

      Ketorolac (Toradol) is a staple in the Emergency department. We often give it when we suspect musculoskeletal causes of pain, when the patient has an orthopedic injury or surgery, or if the patient has renal colic. Toradol can be given in both IM and IV routes. Common dosages are 60mg for IM, and 15-30mg for IV. This is an NSAID – basically the equivalent of IV ibuprofen, so those who are allergic to NSAIDs or those with GI bleeds or significant cardiac disease should probably get something else to be on the safe side. A common misunderstanding is that IV Toradol is safe to give for those with upper GI bleeds or Gastritis since its IV, but the action of Toradol still inhibits prostaglandin synthesis and can lead to stomach irritation and decreased renal perfusion.

      Interestingly enough, it’s possible IM Toradol hasn’t been shown to be more effective for pain control over PO ibuprofen in ER patients [6]. The IV route, however, does offer a more rapid onset of action. I personally think patients seem to think that IV or IM routes offer better relief, and if an IV is already being ordered why not try an IV dose. When used at appropriate doses, side effects from a one-time dose are rare. If present, they can cause dizziness, nausea, or headaches.

      Traditionally 30mg was used for IV dosing, however, this Randomized control trial indicates that IV doses at 10, 15, and 30mg all offered similar pain relief. I usually just order 15mg IV when using this med IV, especially to geriatric patients.

      LIDOCAINE

      Similar to Toradol, Lidocaine can be useful for both musculoskeletal and renal colic – just in different forms. Lidocaine topical patches are often used for musculoskeletal pain from a muscle strain or chronic back pain. A Cochrane meta-analysis indicated that there was “some indication that topical lidocaine offered benefit”, specifically for neuropathic pain, but the trials were poor. Even so, it is often used because of the high safety profile and the limited adverse reactions due to lack of significant systemic absorption.

      5% lidocaine patches should be placed on the most painful area and left for 12 hours. Up to 3 patches can be used at the same time if needed for a large area. When prescribing, brand Lidoderm patches can be expensive at approximately $24 per patch. Without insurance – this is clearly an issue as a 30 count is > $600. A cheaper option is to prescribe 4% lidocaine cream which is about $30 for a month’s supply.

      IV Lidocaine has traditionally been used as an antiarrhythmic for dangerous ventricular cardiac arrhythmias like VTACH or VFIB. However, IV lidocaine has also been shown to offer significant pain relief for various types of pain including neuropathic pain and renal colic [7],[2]. The normal dose is 1.5mg/kg (max 200mg) given slowly over 10 minutes. Cardiac monitoring should be applied during and for 30-60 minutes after the infusion. If given, it should probably be combined with IV Toradol for adjuvant therapy if able to tolerate it. Contraindications include:

      • Allergy to Lidocaine
      • History of seizures
      • Actively Pregnant
      • Hepatic or Renal Failure
      • Severe CAD, heart block, or arrhythmia

      If any serious reaction like seizures or cardiac arrhythmia does occur – intralipid emulsion therapy is the treatment, and this should be readily available in case it is needed – although side effects at the normal dose are rare, with mild transient dizziness being the most common.

      FLEXERIL

      Cyclobenzaprine (Flexeril) is another opioid alternative for musculoskeletal pain, specifically involving the muscles. If there is any type of muscle strain – Flexeril can help relax the muscles and offer some pain relief. This is usually not used alone, but in conjunction with Tylenol, or an NSAID like Ibuprofen/Naproxen. Flexeril should usually be used as a short-term treatment for muscle strains or back pain. Although overall safe, they do have some side effects including sedation, so the patient needs to be able to tolerate this effect and be sure not to drive or work under the influence of Flexeril. Be wary when combining with opioids as they can compound the sedation and risk respiratory depression (Narcan anyone?)

      Other Opioid Alternatives

      There are multiple other specific treatments for pain depending on the source. Reglan works directly on migraine-pain, Pyridium works for bladder pain from UTIs, and even low-dose Ketamine can be used for chronic and perioperative pain. There is also a multitude of non-pharmacologic pain management techniques including heat or cryotherapy, massage, acupuncture, or even guided imagery (never have I ever seen this be a valid option within the hospital).

      These opioid alternatives are not a reason not to give appropriate analgesia to patients in pain. Patients experience real and debilitating pain every day, and opioids are one of our tools to provide them with some relief and aid in their healing. Oftentimes non-narcotic analgesics can be great adjuncts to supplement opioids, or at least a reasonable first step prior to “stepping up” to meds like morphine, Dilaudid, or fentanyl. As always, use your clinical judgment and always advocate for your patients.

      References:

      1. Derry, S., & Moore, R. A. (2014). Topical lidocaine for neuropathic pain in adults. Cochrane Database of Systematic Reviewshttps://www.ncbi.nlm.nih.gov/pubmed/25058164
      2. Firouzian, A., Alipour, A., Rashidian Dezfouli, H., Zamani Kiasari, A., Gholipour Baradari, A., Emami Zeydi, A., Amini Ahidashti, H., Montazami, M., Hosseininejad, S. M., & Yazdani Kochuei, F. (2016). Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. The American Journal of Emergency Medicine, 34(3), 443-448. https://www.ncbi.nlm.nih.gov/pubmed/26704774
      3. Jibril, F., Sharaby, S., Mohamed, A., & Wilby, K. J. (2015). Intravenous versus oral acetaminophen for pain: Systematic review of current evidence to support clinical decision-making. The Canadian Journal of Hospital Pharmacy, 68(3). https://www.ncbi.nlm.nih.gov/pubmed/26157186
      4. Knight, C. L., Deyo, R. A., Staiger, T. O., & Wipf, J. E. (2020). UpToDate. T. W. Post (Ed.). UpToDate. https://www.uptodate.com/contents/treatment-of-acute-low-back-pain
      5. Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., Cohen, V., Filk, N., Smith, A., Huang, F., Rockoff, B., Homel, P., & Fromm, C. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: A randomized controlled trial. Annals of Emergency Medicine, 70(2), 177-184. https://www.ncbi.nlm.nih.gov/pubmed/27993418
      6. Neighbor, M. L., & Puntillo, K. A. (1998). Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Academic Emergency Medicine5(2), 118-122. https://www.ncbi.nlm.nih.gov/pubmed/9492131
      7. Soleimanpour, H., Hassanzadeh, K., Vaezi, H., EJ Golzari, S., Esfanjani, R. M., & Soleimanpour, M. (2012). Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urology, 12(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508963/

      UpToDate Drugs: Acetaminophen | Ketorolac | Lidocaine (systemic) | Flexeril

      9 Nursing Medication Errors that KILL

      9 Nursing Medication Errors that KILL

      William J. Kelly, MSN, FNP-C
      William J. Kelly, MSN, FNP-C

      Author | Nurse Practitioner

            

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      Did you know that Medication errors are the 3rd leading cause of death in the United States – right behind heart disease and cancer?

      Med errors account for more than 250,000 US deaths every year. Medications save lives every day, but unfortunately, these same medications can also hurt our patients if given inappropriately.

      Now, most nursing medication errors don’t actually kill our patients, but they do increase morbidity, increase hospital admissions and length of stay, as well as decrease the quality of life of our patients.

      As nurses administer almost all of the medications within the hospital, this means that nurses are on the front lines and will be responsible for causing or preventing these nursing medication errors from occurring.

      While nurses are not the ordering Provider, it takes a team of nurses, doctors, pharmacists, and patients to decrease these med errors from occurring.

      1. Nitro Paste


      There’s a reason that Nitropaste only seems to be good for one thing… causing headaches! One of the reasons that Nitropaste doesn’t work well sometimes is due to medication errors in administration!

      If you’re anything like I was as a new grad – you may have been taught to squirt put a thin line of nitro-paste to the ½ inch or 1-inch mark (whichever was ordered by the Provider).

      This leaves a good amount of paste leftover in the Nitrobid individual packet. What some nurses fail to realize is that this is incorrect dosing!

      Each individual packet of nitrobid 2% is usually preloaded (pun intended) with 1 gram or about 1 square inch of ointment. So if the provider orders ½ inch, squirt out half the packet on the application paper, or squirt the whole thing out if 1 inch is ordered.

      Now you might be saying “OK, but underdosing of Nitropaste isn’t exactly killing my patient”. But you see – it can! Nitroglycerin is a SUPER important medication when treating acute coronary syndrome (i.e. heart attacks!).

      If the patient has a blocked coronary artery, nitro will dilate those arteries, improve blood flow around the obstruction, and can lead to saved cardiac tissue and potentially also saving a patient’s life!

      It is also very helpful for decreasing preload and afterload in your CHF patients – so it is important to make sure the patient is receiving the correct dose!

      2. Ceftriaxone and Lactated Ringer’s

      Intravenous medication drips are very common within the hospital – especially IV fluids, antibiotics, and even critical drips within the ICU.

      Oftentimes our patients will have IV fluids running as primary, and they may also have secondary IV pushes or IV antibiotics.

      This really isn’t an issue with Normal Saline, as just about every drug is compatible with NSS.

      However, sometimes Lactated Ringer’s (LR) or another fluid is ordered instead. Don’t give ceftriaxone (Rocephin) with IV LR, as this can form precipitates that can harm the patient.

      This is because there is calcium within the LR, and Ceftriaxone + Calcium = bad! These precipitates can cause damage to your kidneys, lungs, or gallbladder.

      This can be missed in the ED where many nurses have to mix their own antibiotics and hang it secondary to whatever fluid is running. If this is LR – this can lead to issues as above.

      This is just another example of how ER nurses need to be hypervigilant about preventing medication errors like this from occurring – while simultaneously managing life-threatening emergencies of their patients.

      Also check out: Intravenous Fluids: Types of IV Fluids

      3. Paralytic Before Sedation

      Rapid Sequence Intubation (RSI) is the term used to define the methods taken to intubate a patient who is awake (for now).

      Considering we’re about to stick a tube down their trachea and breathe for them – this requires sedation!

      To prevent the body from fighting against the intubation, this requires medication to paralyze them – a paralytic.

      During RSI, there is a specific sequence that must be followed.

      You must ALWAYS GIVE SEDATION BEFORE THE PARALYTIC.

      Why you ask? Well.. isn’t it obvious? If you paralyze someone before knocking them out – they are going to be TERRIFIED.

      They won’t be able to breathe or move, and will be aware of the whole ordeal… So no – this won’t kill the patient, but this nursing medication error will make the whole process much more traumatic, and the patient can remember the whole thing when they wake up.

      Common IV sedatives (Induction agents) include: etomidate, midazolam, ketamine, fentanyl, propofol, thiopental.

      Common IV paralytics include: succinylcholine, rocuronium, vecuronium.

      4. IV Insulin

      It doesn’t take long working as a nurse to realize how COMMON diabetes is in hospitalized patients.

      This is because uncontrolled diabetes eats away at basically every body system that you have. Your kidneys fail, your nerves are destroyed, your eyes go bad, and your arteries clog up!

      Diabetics often come in for Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), or a patient may just need IV insulin for hyperkalemia (to push the K+ back into the cells).

      Insulin is usually given SubQ, so some nurses may not be used to giving it through the IV. Those SubQ insulin needles don’t hook up to a needleless IV system – so what do you do?

      Some facilities have special adapters, but honestly, the EASIEST way to do this is to draw the insulin up in your normal Subcutaneous syringe anyway. This will usually be 5-10 units. VERIFY this dose with other nurses – most facilities will require this.

      Then, take a sterile NS flush, squirt half out, pull back on the syringe to make room, and squirt the insulin into the syringe. Essentially you’ve just diluted the insulin with ~5mL of saline.

      Don’t set down the syringe – label it per facility protocol and give it to the patient the same way as any other IV push medication.

      This may seem simple to some, but many nurses draw up the insulin in a regular 3mL syringe. I’ve seen nursing medication errors occur, and sometimes the patients are given up to 10x the ordered dose.

      This obviously leads to hypoglycemia and a need for close monitoring. Worst case – this med error can lead to death, and there have been accidental deaths due to insulin overdoses.

        CLINICAL TIP

      As a side note, when verifying ANY high-risk medication, make sure you look at the syringe AND the vial. I once had a nurse ask me to verify their 1mL (5,000u) subQ heparin dose. Turns out she had actually drawn up 1mL of INSULIN LISPRO! That’s 100 units! MUCH higher than most can tolerate. This med error was avoided by being diligent about verifying both the syringe amount and the vial.

      5. Sound Alike – Look Alike

      You may have heard about this , but a nurse in Tennessee had accidentally killed a patient when she administered VECURONIUM instead of VERSED.

      This was apparently ordered to calm the patient down at MRI, so the nurse grabbed it out of the accu-dose, had overridden the medication, and administered the paralytic to the patient at CT.

      Now – there are MANY nursing errors in this scenario, so let’s talk about them.

      Overriding the Accudose System

      This is usually a major no-no on the floors, but in the ED this is common for Pain meds, Zofran, Ativan, etc.

      In the ED, they don’t always have the luxury of waiting for the pharmacy to verify medications, and some systems won’t even have the pharmacist verify ED physician orders.

      If you absolutely HAVE to override, make sure you are hypervigilant about which medication you are pulling out, reconstituting, etc.

      If you are unsure of a medication – ASK for help! You shouldn’t be giving a medication that you don’t know about anyway.

      Always know the intended use, appropriate dosing, and potential side effects to monitor for! There are many sound-alike-look-alike drugs, and it can be common to make these nursing med errors if you aren’t careful!

      Appropriate Monitoring

      Monitoring the patient is an essential aspect of appropriate nursing management. As nurses, you are at the bedside and will be the first ones to notice a change in a patient’s status.

      Monitoring is especially important after the administration of ANY IV medication, but especially high-risk meds like IV narcotics or sedatives.

      This nurse was going to give IV versed to a patient at MRI. This patient was NOT hooked up to the monitor, the nurse had injected the medication and reportedly left back to the ER.

      If you are giving IV versed, you should always have your patient on a monitor – at the least a pulse ox machine. Because she had given VECURONIUM instead of versed, her patient was paralyzed and couldn’t breathe – causing her suffocation in the MRI machine.

      Appropriate monitoring of the patient, even after administering the wrong medication, would have saved the patient’s life.

      6. IV Haldol

      Speaking of monitoring, it is also necessary to have cardiac monitor during and after administration of certain medications.

      This is because some medications can cause arrhythmias, and you want to be able to immediately identify them and recognize the need for rapid action.

      Haldol can be given IV due to agitation or dementia, and sometimes for nausea. Unfortunately, this medication is high-risk for cardiac arrhythmias by increasing QT, predisposing the patient to PVCs, VTACH, Torsades, and even VFIB.

      It also is worth noting that Haldol is technically to be avoided in cases of dementia-related agitation due to an increased risk of sudden death.

      While our options are limited and Haldol may still need to be given, appropriate measures including cardiac monitoring should be used, at least when given IV.

      Also check out:

      7. IV Push Not IV Slam

      Giving IV push medications is very common in the hospital: Zofran, IV narcotics, Toradol, and Lasix (among many others).

      Nurses can be busy, so this can tempt us to quickly give the medication and immediately move on to the next task.

      However, sometimes medications that are given too fast can cause unpleasant side effects for the patient, some even disastrous.

      Dilaudid

      Dilaudid (hydromorphone) is a common IV narcotic given for pain.

      This is the “heavy hitter”, and is approximately 7 times stronger than morphine.

      Dilaudid should be given slowly over 2-3 minutes.

      Administering Dilaudid more rapidly has been associated with increased side effects, specifically respiratory depression and hypotension.

      This is true for other IV narcotics as well like morphine and fentanyl.

      As a quick tip, you can dilute the dilaudid in 50-100ml of NS and then administer it slowly over 10-15 minutes.

      Reglan

      IV Reglan (metoclopramide) can be given IVP in doses ≤ 10mg undiluted over 1-2 minutes.

      If pushed too fast, this can cause an intense but short-lived feeling of anxiety and restlessness, followed by a period of drowsiness.

      This is very common with Reglan, especially in younger females!

      A small dose of Benadryl is often ordered to treat the restlessness, but note this will increase the drowsiness experienced afterward.

      Be on the lookout for true dystonic reactions, characterized by involuntary contractions of the muscle of the body.

      Cardiac Medicationss

      Cardiac medications like Lopressor (metoprolol) and Cardizem (diltiazem) should be pushed slowly in order to prevent adverse events from occurring.

      Side effects include bradycardia and/or hypotension.

      Lopressor should be pushed over 2-5 minutes and Cardizem over 2 minutes.

      Dexamethasone

      Doses of IV dexamethasone 4-10mg are often given undiluted over <1 minute.

      However, rapid administration is associated with perineal irritation.

      Patients will tell you “my crotch is on fire!”.

      This can even happen with slow administration, so warn the patient that this is a possible side effect, is short-lived, and will go away on its own.

      Its recommended to dilute it in a 50ml bag and run it over 5-15 minutes to minimize this occurrence.

      Also Check out: Adverse Drug Reactions Nurses Need to Know

      8. Proper IM Location

      When I was a nurse I was taught to inject most IM medications >1mL in the butt. However, where I was injecting in the butt wasn’t really specified.

      Many nurses just shoot for the middle of the buttock (dorsogluteal), but this can actually cause all sorts of injury to the patient.

      While not super common, injecting in the dorsogluteal region can lead to skin and tissue trauma, muscle fibrosis and contracture, hematoma, nerve palsy, paralysis, and infection. 

      Instead, these medications should be given in the ventrogluteal site.

      IM injections should be given in the ventrogluteal site to avoid complications

      The Deltoid muscle is an easy location for all injections 1-2mL in most adults. However, even 1 mL can be very painful in the deltoid depending on the patient.

      This is also not a recommended site if giving repeat injections, as the surface area of the muscle is not very high.

      An important fact to know about intramuscular injections is that the vastus lateralis (the side of the thigh) actually offers the quickest absorption.

      This means that if you have a patient come in for a severe anaphylactic reaction – your best bet is to inject the epinephrine in the thigh as opposed to the arm.

      9. Broad Before Narrow

      Antibiotics are given ALL the time within the hospital.

      Patients may be septic and need immediate treatment including multiple IV antibiotics.

      Some antibiotics have a very broad spectrum – eaning they kill all sorts of bacteria. Others have a narrow spectrum, meaning they kill fewer bugs.

      You always want to make sure to hang the broad-spectrum antibiotic first. This ensures that the antibiotic most-likely to help will be given first.

      One common mistake is nurses think Vancomycin is broad-spectrum because it is a “heavy hitter”, but Vancomycin is actually narrow!

      Vancomycin mainly only covers gram-positive organisms!

      This means unless the bacteria is actually MRSA or another Gram-positive infection, Vancomycin is less likely to help. PLUS it takes a while to infuse anyway (like 1.5-2 hours).

      The best decision in sepsis is to hang the broad-spectrum antibiotic first. Common examples of broad-spectrum antibiotics include:

      • Ceftriaxone (Rocephin)
      • Cefepime
      • Pipericillin-Tazobactam (Zosyn)
      • Imipenem
      • Ampicillin

      And there you have it! With great power comes great responsibility. Nurses are responsible for administering life-saving medications, but these medications can also hurt if given inappropriately.

      We must be vigilant in avoiding nursing medication errors and improve our patient-outcomes.

      Do you know of any other common nursing medicaiton errors? Let us know in the comments below!

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