Newtwo

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Hey

I do some locums in some smaller places when all ive worked at is ivory towers til now...
They dont have all the equipment and meds etc freely available that other places have
Just simple things

So...

They dont easily have 1 ml syringes. Is it ok to use 2 or 3ml syringes to draw up narcotic for intrathecal use like it morphine? I usually use 15 mcg fent and 150 mcg epimorph for spinals

The also don't have glass vials for fent/epimorp so to draw up IT meds you have to push thru a regular plastic membrane with the blunt needle. Is that okay?

Lastly they dont have many blunt needles with the filter on it for drawing up IT meds. Is that ok?

Thank you
Sorry, stupid. Qs!!
 

IMGASMD

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Hey

I do some locums in some smaller places when all ive worked at is ivory towers til now...
They dont have all the equipment and meds etc freely available that other places have
Just simple things

So...

They dont easily have 1 ml syringes. Is it ok to use 2 or 3ml syringes to draw up narcotic for intrathecal use like it morphine? I usually use 15 mcg fent and 150 mcg epimorph for spinals

The also don't have glass vials for fent/epimorp so to draw up IT meds you have to push thru a regular plastic membrane with the blunt needle. Is that okay?

Lastly they dont have many blunt needles with the filter on it for drawing up IT meds. Is that ok?

Thank you
Sorry, stupid. Qs!!

Not sure if you’re totally serious..... but I will play.
Yes. Your narcotic doses usually doesn’t affect your spinals that much. I’ve been to place that don’t use any fentanyl in their spinals. My old training program used to give 500mcg of duramorph for spinals, but I now use 250mcg.

There are pliers that will remove the top of the vials so you don’t have to poke through membrane. If I have to go through, I usually take off the cap, put a alcohol wipe on top, just for my peace of mind.

Usually there is a filter needle in the tray, I’d use that. Remembering there was a discussion about using regular 18G needle going through propofol bottle and get floaters around.
 

drmwvr

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pop the top of the non-sterile vials and reserve them off of your sterile field...draw them up with the kit provided stuff.
 
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Gator7

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Yea just use pliers for the vials. And shouldn’t need the filter needle if not cracking a glass vial.
I typically just use the glass syringe in the kit and if you change your narcotic to 20mcg fent and 200mcg morphine it’s easy to eyeball. Ex: draw 1.4ml bupi followed by 20mcg fent and 200mcg morphine comes out to 2ml.
 
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Velefunt

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I routinely use the 3ml syringe in SAB kits to draw both my intrathecal morphine and local. You can draw up 0.2ml easily and "drop" a little out to get ~150mcg, although 200mcg won't necessarily ruin anybody's day. I'll draw the narc first then the local.

I also pop the top off the 10ml vial of duramorph. Rather than use those pliers for popping off tops, I routinely use trauma shears. The small amount of metal near the handles makes a great lever to pop the tops off. Practice with your propofol vials. Imagine popping off the cap on a beer. So to reiterate, one end of the shear under the cap and one end on the top, lever it off. Set it off to the side of your open kit like everyone else says.

It pays to be flexible and adaptable.

BTW, if you're using a spinal kit, doesn't it come with a filter straw or needle?
 
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Not sure if you’re totally serious..... but I will play.
Yes. Your narcotic doses usually doesn’t affect your spinals that much. I’ve been to place that don’t use any fentanyl in their spinals. My old training program used to give 500mcg of duramorph for spinals, but I now use 250mcg.

There are pliers that will remove the top of the vials so you don’t have to poke through membrane. If I have to go through, I usually take off the cap, put a alcohol wipe on top, just for my peace of mind.

Usually there is a filter needle in the tray, I’d use that. Remembering there was a discussion about using regular 18G needle going through propofol bottle and get floaters around.

Above 200 you don't get better pain control and there are more side effects
 
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SaltyDog

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Drawing up IT meds in anything other than a 1mL syringe is gross malpractice. Personally I’m shocked you haven’t been assassinating patients left and right with your reckless technique. :nono:
 
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Twiggidy

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I find it surprising a TB syringe would be that hard to find in a hospital
 
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narcotics999

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I find it surprising a TB syringe would be that hard to find in a hospital
My CRNA once drew 40units of insulin using TB syringe. Luckily I was looking... (well my instinct was telling me she was going to make this mistake)
 
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nimbus

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What was she doing with that much insulin?

Maybe they were trying this...

“In addition, patients invariably emerged from the long course of treatment "grossly obese".[5] The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively.[1][6] A study at the time claimed that many of the cases of brain damage were actually therapeutic improvement because they showed "loss of tension and hostility".[13] Mortality risk estimates varied from about one percent[2] to 4.9 percent.”

 
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chocomorsel

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It’s one of those classic rookie nurse mistakes - thinking it’s 10u/mL instead of 100u/mL. I think @Hawaiian Bruin has a good story from his internship taking care of a patient that got 100u.
Except this is a CRNA. Not a brand new nurse. So how is a CRNA a rookie nurse? That's LPN stuff right there. I was an LPN. Come on.
 
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You need ridiculously high dose insulin drips for calcium channel blocker toxicity but it's pretty rare.

Know of a resident who gave 100 units IV.
 

Hawaiian Bruin

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It’s one of those classic rookie nurse mistakes - thinking it’s 10u/mL instead of 100u/mL. I think @Hawaiian Bruin has a good story from his internship taking care of a patient that got 100u.
500u actually. They meant to give 5mg metoprolol. D’oh! The patient thought it was hilarious. He kept laughing and saying “Y’all f^c&ed up, huh?!?”
 
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nimbus

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I have presbyopia so I hate measuring out insulin in TB syringes. Whenever I give insulin, I order a 1u/ml insulin drip and draw it out of the bag.
 
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Twiggidy

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500u actually. They meant to give 5mg metoprolol. D’oh! The patient thought it was hilarious. He kept laughing and saying “Y’all f^c&ed up, huh?!?”
So much wrong happening there especially since Insulin comes from the fridge. About once a quarter we have to raise hell with pharmacy when some new batch of Zofran comes in that looks identical to phenylepherine
 
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chocomorsel

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So much wrong happening there especially since Insulin comes from the fridge. About once a quarter we have to raise hell with pharmacy when some new batch of Zofran comes in that looks identical to phenylepherine
Except one is 2cc and the other is 1cc. That ought to make you realize the difference. No?
Anyway, they do look alike.
 

Hawaiian Bruin

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So what did you do? How did you resolve the situation?
So they transferred to me in the ICU, intern essentially alone in house at night. I put in an a-line and drew Q15 minute gasses at first, and tapered the frequency off as needed. I forget how many sticks of D50 I went through but I wanna say like 12. And a bunch of potassium.

The unanticipated learning point for me was actually that the phos gets crazy low too and there was a bunch of k-phos given along with the other stuff.

The BG never dropped below the 80s since we were constantly pushing sugar. Honestly, as an intern, the whole thing was pretty fun. I was of course terrified at first when I got the call of what had happened. But once I realized he wasn't gonna die from this since we were all over the situation, it was about as good as a night in the unit gets for an anesthesia intern learning to manage critical stuff on his own. And the patient honestly thought it was hilarious and was in good spirits throughout.

It may not shock you all to learn that this happened at a VA hospital. It was a student nurse that pushed it under the alleged supervision of a precepting RN. The quality of the preceptor RNs at the old local VA was, shall we say politely, somewhat marginal.

tl;dr our vets deserve better than the intern version of me being all that stands between them and certain iatrogenic doom.
 
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vector2

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I never pop caps off anything. I just draw stuff up through the stopper. So never smelled it.
With just the top cap off but the stopper still on I still smell it. Heh anyways I googled it

"
Overall, people commonly described the smell of insulin as “band-aids” both the cloth kind and new kind. According to the National Institute of Health (NIH), insulin has a chemical compound to stabilize, acts as an antiseptic, and disinfectant the liquid. This chemical compound is called phenol."

Yep bandaid smell, that's it
 
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chocomorsel

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It’s not even intentional. You just pop the cap off of one of those 100u/ml vials and it hits you in the face
Once you pop off the caps and are done with your case do the vials end up in the trash? Or are they still reusable?
I ask because I don’t really think insulin is a cheap drug even though it should be. And it’s supposed to be a multi use vial.
If it was cheap I doubt I would be reading articles of people rationing it and dying in the process. But I could be wrong.

Edit.. maybe I misunderstood. You are not removing the rubber cap? Just the metal lid?
 

chocomorsel

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With just the top cap off but the stopper still on I still smell it. Heh anyways I googled it

"
Overall, people commonly described the smell of insulin as “band-aids” both the cloth kind and new kind. According to the National Institute of Health (NIH), insulin has a chemical compound to stabilize, acts as an antiseptic, and disinfectant the liquid. This chemical compound is called phenol."

Yep bandaid smell, that's it
WTH do bandaids smell like? And why have I never noticed considering my brother tells me I should work for the police as my sense of smell is so strong?
 
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fittipaldi1of1

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With just the top cap off but the stopper still on I still smell it. Heh anyways I googled it

"
Overall, people commonly described the smell of insulin as “band-aids” both the cloth kind and new kind. According to the National Institute of Health (NIH), insulin has a chemical compound to stabilize, acts as an antiseptic, and disinfectant the liquid. This chemical compound is called phenol."

Yep bandaid smell, that's it
Now I’m going to have to smell this
 

abolt18

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Speaking of a silly question...does anyone know why insulin smells so weird?
Agreed, insulin smells weird. Not sure about the band-aid thing though. For me I've smelled it when spiking a bag of insulin and running it through the tubing, some drips out into the floor or onto my gloves.
 
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SaltyDog

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So much wrong happening there especially since Insulin comes from the fridge. About once a quarter we have to raise hell with pharmacy when some new batch of Zofran comes in that looks identical to phenylepherine

What? - you think someone could actually mix these up??

1E0EB7CB-84F6-457A-8B9E-EE50F9555944.jpeg
75EFF4DD-C031-467E-8991-BAB40DFDA57B.jpeg
 
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rakotomazoto

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people use TB syringes? we only have them in pediatric cart i believe... for the really small kids..
If you haven't tried a TB syringe, you ought to. It was a game-changer for me. I should mention that we don't use glass vials, so I am not sure if it would remain my method of choice then.

The needle is already attached to the syringe, small amounts are easy to measure. It's a very efficient way to draw up ITN for your spinal. No need for pliers or risk that open containers/vials are going to spill or get contaminated somehow.
 

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I think it’s asinine, as hard a time as pharmacies generally give us, that they’d stock 10mg/ml phenylephrine in our carts as opposed to pre-filled syringes. And they’ll do it straight-faced putting it right beside a zofran that looks exactly the same. That right there is lacking good common sense, my friends.
 
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SaltyDog

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What really irks me is when they change suppliers/vials without letting us know in advance.
 
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I think it’s asinine, as hard a time as pharmacies generally give us, that they’d stock 10mg/ml phenylephrine in our carts as opposed to pre-filled syringes. And they’ll do it straight-faced putting it right beside a zofran that looks exactly the same. That right there is lacking good common sense, my friends.

Have them put it in a bag in the back
 

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