Adverse Drug Reactions Nurses NEED to know

Adverse Drug Reactions Nurses NEED to know

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!

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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!

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Intravenous Fluids: Types of IV fluids

Intravenous Fluids: Types of IV fluids

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.

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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”

Intravenous Fluids IVF - 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/

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Opioid Alternative Analgesics in the ER

Opioid Alternative Analgesics in the ER

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

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 physician, 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! I’ve found that Nitropaste doesn’t work well oftentimes 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 physician). This usually 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. If the patient has an acute coronary artery blockage (or similar pathology), nitroglycerin can quite literally 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 acute decompensated heart failure 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. With LR, you want to avoid giving IV Ceftriaxone (Rocephin), as this may cause precipitates from forming which can harm the patient. This is because there is calcium within the LR, and Ceftriaxone + Calcium = bad! These precipitates can theoretically cause damage to your kidneys, lungs, or gallbladder.

 

This may not be a HUGE issue on the floors, since pharmacy often sends IV antibiotics to the floor and may caution the nurse not to run the ceftriaxone secondary to the LR. However, in the ED – they sometimes 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.

3. Paralytic Before Sedation

Rapid Sequence Intubation (RSI) is the term used to define the methods taken to intubate a patient who is not unresponsive (yet!). 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.
In the ER or wherever the patient is being intubated, 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 cognizant of it… So no – this won’t kill the patient, but this nursing medication error will make the whole process much more traumatic, and the patient may 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). IV insulin may be ordered for your patients with these conditions.
 
Insulin is usually given in a subcutaneous manner, so some nurses may not be used to giving it 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. Now 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.
 
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 in the news, 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 I can tell you from firsthand experience, working in the ED, it is often done for many medications like Pain meds, Zofran, 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. The nurse, in this case, 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 their 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 is a medication that I often see being administered IV due to agitation or dementia. 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.

7. IV Push Not IV Slam

Giving IV push medications is commonplace within the hospital. Usually, these are medications like Zofran, IV narcotics, Toradol, and Lasix (among many others). Nurses can be busy, so this can tempt us to quickly give the medication and 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” that providers can order for pain, and is approximately 7 times stronger than morphine. Ideally, Dilaudid should be given over 2-3 minutes, as 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 (morphine and fentanyl). As a quick tip, many nurses will dilute the Dilaudid in a 50ml bag and run it over 15 minutes. Just be aware that a small amount of this medication will be wasted within the tubing itself.

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. 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 Meds

Cardiac medications like Lopressor (metoprolol) and Cardizem (diltiazem) should be pushed slowly in order to prevent adverse events from occurring. Typically these include bradycardia and/or hypotension. Lopressor should be pushed over 2-5 minutes and Cardizem over 2 minutes.

Dexamethasone

Doses 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.

8. Proper IM Location

OK – so not quite a medication error, but hear me out. 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. This 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 (google it!).

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

Again – not really a medication error, but more of a nursing administration error. Antibiotics are given ALL the time within the hospital. Many times, patients are septic and need immediate treatment including multiple IV antibiotics. Some antibiotics have a very broad spectrum – meaning 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 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. 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 have any other nursing medication errors to avoid? Let me know in the comments below!

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