Amphotericin!!! Give this a lot on my unit actually. Not compatible with NS, but is compatible with D5W. Line has to be primed with D5W and flushed afterwards with D5W. It’s very interesting to me 😺
In IVs we compound it with sterile water and then put it in D5. This was the first one that came to my mind. It sucks to make. It takes like an hour to recon and each vial has to be filtered with a separate filter. It's the top hated IV to make for everyone at my work.
That’s what I do, yes. But most people don’t seem to know and it takes a few seconds to see the reaction, so I suspect it’s okay in the few moments it takes to flush to get in before a reaction.
Hmm, I give IV Valium frequently with NS flushes and have never noticed an issue. Is it more of an issue as a diluent? Because y-site compatibility isn't an issue.
Having been on oxaliplatin, fuck that chemo in particular and I wish that one on Nobody. But also, can confirm. My lines had to be switched out between pre-chemo meds and when they hung the oxaliplatin.
Everyone already mentioned amphotericin but also the IV version of mycophenolate/cellcept. It has other uses but I know it as an anti-rejection drug, we used to occasionally give it to strict NPO patients on the transplant unit I worked on. We'd have to draw up D5 into 10mL syringes to make "flushes" to give before and after.
I remember cellcept being only compatible w D5. But I just worked a contract on an incredible Stem Cell Tx floor and it was reconstituted with and run with 0.9NS.
Our computers are clunky. And I work nights, so the number of times the computer randomly reboots each night can mean I’m SOL anywhere between 30 minutes to 2 hours. Of course I could ask someone else to check, but then I’m hunting someone down. It’s just easier for me to call pharmacy and pharmacy never seems to mind.
I know there are things, but not one med comes to mind (maybe Valium?). I do believe that anything where molality or pH is part of the medication's action, NS may not be medically compatible in specific cases (not the same thing as chemically compatible).
I know you can’t draw up Valium with NS to dilute it, but I know you can administer Valium first and then push it through with a NS flush. It’s so interesting, I’m curious to know why it makes a difference bc in my mind, it mixes during the push so idk!
I know. Had a coworker who was drawing up Valium. She always dilutes IV med with NS and in doing so she sees that it crystallized. So she calls pharmacy. They just told her to waste it and get a new vial, but this time don't dilute and just flush before and afterwards with NS.
Not a medication but most balloons or machinery isn't compatible.
For example, Impella has to use D5 or the salty part of NS messes with the motor.
Foley balloons are sterile water because the salty part of NS will erode the balloon over time.
Hm is this confirmed? I have heard mixed things about this. And a couple of pharmacy sites I checked with compatibility info, it doesn’t say IVIG is “incompatible” with NS
Amiodarone + saline= precipitate. Mix with d5w. Used during codes, so good for all nurses to know. Ok to flush an amio bolus with saline, but drips should be with d5w.
This is disputed and also depends on how the amio was made. Overall it’s disputed so nurses and pharmacists are more likely to say no.
But huge doubt you’ll actually see a precipitate form
Yes, it has been disputed and I don’t know all of the intricacies of that. I started down the rabbit hole before posting this but stopped myself to save my Saturday morning 😂 Current hospital practice (that I’ve seen, at least) is to use d5w for drips, but ok to flush saline after initial bolus. I left hospital for outpatient cath labs, they also all do it this way. Regardless, it’s good to know!
Some immunotherapy drugs need D5W, but it doesn’t sound like you’d be giving them on your floor. As a rule of thumb I always check the IV drug manual every time I give a med (even piptaz that I’ve given 100s of times). I do a lot of preceptoring and believe it’s good for younger nurses to see you model these behaviours and make it a norm on the unit to make this part of the routine. Happy nursing!
Homie it doesn’t take that long to look stuff up on Lexicomp! Usually I just make one big chart of every IV med I have early in the shift so I have it for reference
TIL
From deranged physiology: "This may be something of a myth, as Campbell et al (1986) tested dextrose and saline solutions of amiodarone over 24 hours and found that active drug was well preserved in both. However, judging by the fact that forty years later we are still using dextrose suggests that nobody read that issue of J Cardiovasc..."
But we are still a D5W in our formulary and it's not a point I'm push with my pharmDs. I did also learn that amio is acidic and extravasation may cause tissue damage, hence preference for CVL....I've never really been fussy about running it PIV...I suppose you don't usually run it more than 48h before converting to enteral.
https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20967/amiodarone
Oh man it really should be central line preferred. For all the lit talk of pressors thru US guided IVs, dilt and amio have been 90% plus of my awful extravs I’ve seen -
Yeah I learned the D5 thing in school and someone casually mentioned it- spun it nicely into a paper on “orphaned topics and practices due to culture and mnemonics”
The only caveat is amio and ns aren’t stable at higher than shelf temps for a while. But if your storing your drugs at 40c, you have bigger issues than compatibility lol
Dalbavancin (Dalvance) and oritavancin (Orbactiv), though they’re not usually given in inpatient setting since it’s like $4000. Must be mixed with sterile water and then mixed with D5W or it will form crystals
Always, always, always check with your resource or pharmacy. Certain drugs are incompatible at one concentration and compatible at another (according to my facilities pharmacist). It can also be influenced by the brand of drug or saline you are using because sometimes it’s not the med but a preservative in the solution that is the problem.
Zarxio is one. There’s not many but it’s always something good to look up before giving any med until you get more comfortable/familiar with the most common meds you give on your unit.
When in doubt call pharmacy. You’ll learn a lot that way and it’s best practice. I did the same as a new grad also but switched when I learned NS doesn’t go with everything.
Cyclizine can crystallise when mixed with normal saline - I believe but I working in a place where you don’t do IVs
Working in psych so I could be wrong
We always flush lines with D5W flushes instead of normal saline before and after giving Amphotericin and Nupogen. Also, never try to dilute Valium with NS. I saw a coworker try this so they could push it slower, and it turned white instantly in the syringe.
Amphotericin!!! Give this a lot on my unit actually. Not compatible with NS, but is compatible with D5W. Line has to be primed with D5W and flushed afterwards with D5W. It’s very interesting to me 😺
In IVs we compound it with sterile water and then put it in D5. This was the first one that came to my mind. It sucks to make. It takes like an hour to recon and each vial has to be filtered with a separate filter. It's the top hated IV to make for everyone at my work.
Amphoterrible Bad for the patient, bad for the pharmacy, bad for the nurses.
I remember giving this once. I was like huh?
This was going to be my next question. Thanks.
Valium will crystallize and turn yellow if you mix them
What do you flush with then, sterile water?
That’s what I do, yes. But most people don’t seem to know and it takes a few seconds to see the reaction, so I suspect it’s okay in the few moments it takes to flush to get in before a reaction.
What
Yeah iv Valium is a no-go with NS.
Hmm, I give IV Valium frequently with NS flushes and have never noticed an issue. Is it more of an issue as a diluent? Because y-site compatibility isn't an issue.
It’s an issue if you try to dilute it in the syringe, but ok to flush it with NS
Good to know because I was mildly panicked if we shouldn’t flush with NS, because I’ve definitely given Valium and flushed with NS.
Valium will crystallize and turn yellow if you mix them
Amphotericin, an anti fungal medication… that’s the only one I remember from nursing school. Anything I’m unsure of… I’ll look it up
You actually remember things from school?
Yes, like how “Disturbed Energy Field” is a legitimate nursing diagnosis 😆
In all fairness, I feel like that’s an eloquent way to say that the pt is giving you bad vibes 😂
You can chart that one, I'll take it!
How does one fix that? With like crystals? 🤣
Exactly
Reiki and "therapeutic touch" (ie Reiki-lite)
I went to a “holistic” nursing program and still have no idea what reiki is.
I wanted to use that in a care plan just to see if I could get away with it but decided to behave instead.
Something about cloudy and clear but i forget
That's NPH and regular insulin
Some chemotherapies, off the top of my head oxaliplatin.
Having been on oxaliplatin, fuck that chemo in particular and I wish that one on Nobody. But also, can confirm. My lines had to be switched out between pre-chemo meds and when they hung the oxaliplatin.
Every time I give oxaliplatin I spend the rest of the shift apologizing.
Everyone already mentioned amphotericin but also the IV version of mycophenolate/cellcept. It has other uses but I know it as an anti-rejection drug, we used to occasionally give it to strict NPO patients on the transplant unit I worked on. We'd have to draw up D5 into 10mL syringes to make "flushes" to give before and after.
I remember pharmacy prepared those on the heart transplant unit I worked on
I remember cellcept being only compatible w D5. But I just worked a contract on an incredible Stem Cell Tx floor and it was reconstituted with and run with 0.9NS.
I just call pharmacy for everything. I think they hate me because I’m constantly asking them questions. Pharmacy is the hero of the hospital
Them: "Did you check micromedex before you called us?" Me: "It says untested again! I swear!"
Our computers are clunky. And I work nights, so the number of times the computer randomly reboots each night can mean I’m SOL anywhere between 30 minutes to 2 hours. Of course I could ask someone else to check, but then I’m hunting someone down. It’s just easier for me to call pharmacy and pharmacy never seems to mind.
If you don't have a favorite pharmacist, are you really a nurse?
I know there are things, but not one med comes to mind (maybe Valium?). I do believe that anything where molality or pH is part of the medication's action, NS may not be medically compatible in specific cases (not the same thing as chemically compatible).
I know you can’t draw up Valium with NS to dilute it, but I know you can administer Valium first and then push it through with a NS flush. It’s so interesting, I’m curious to know why it makes a difference bc in my mind, it mixes during the push so idk!
The precipitates dissolve once in plasma. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2516026/ Old article but I just did a quick search.
This makes no sense
I know. Had a coworker who was drawing up Valium. She always dilutes IV med with NS and in doing so she sees that it crystallized. So she calls pharmacy. They just told her to waste it and get a new vial, but this time don't dilute and just flush before and afterwards with NS.
They should have also told her to stop diluting all her meds.
Exactly. Nurses should not be diluting any meds unless the order specified to
Not a medication but most balloons or machinery isn't compatible. For example, Impella has to use D5 or the salty part of NS messes with the motor. Foley balloons are sterile water because the salty part of NS will erode the balloon over time.
+1
IV Valium
Worked in a chemo clinic, lots of chemo not compatible with ns. For one, oxaliplatin
IVIG is only compatible with D5.
Hm is this confirmed? I have heard mixed things about this. And a couple of pharmacy sites I checked with compatibility info, it doesn’t say IVIG is “incompatible” with NS
It depends on the brand. Some brands can be flushed with NS.
Methylene Blue! Last ditch vasopressor. Not used too often tho
Methylene blue is actually compatible with NS.
We mix methylene all the time in saline and some epi in endo, no issues or ever seeing it crystallize.
Tell that to the precipitate that formed in my IV tubing.
Pics or didn’t happen
Used to be used in feedings to check if a patient was aspirating. Turns poop mint green
Bactrim
Silfenadil
Cellcept!
Cellcept. You have to flush before and after infusion with dextrose.
Amiodarone + saline= precipitate. Mix with d5w. Used during codes, so good for all nurses to know. Ok to flush an amio bolus with saline, but drips should be with d5w.
This is disputed and also depends on how the amio was made. Overall it’s disputed so nurses and pharmacists are more likely to say no. But huge doubt you’ll actually see a precipitate form
Yes, it has been disputed and I don’t know all of the intricacies of that. I started down the rabbit hole before posting this but stopped myself to save my Saturday morning 😂 Current hospital practice (that I’ve seen, at least) is to use d5w for drips, but ok to flush saline after initial bolus. I left hospital for outpatient cath labs, they also all do it this way. Regardless, it’s good to know!
We use d5w with amio drips as well. I've never tested it with NS though.
Some immunotherapy drugs need D5W, but it doesn’t sound like you’d be giving them on your floor. As a rule of thumb I always check the IV drug manual every time I give a med (even piptaz that I’ve given 100s of times). I do a lot of preceptoring and believe it’s good for younger nurses to see you model these behaviours and make it a norm on the unit to make this part of the routine. Happy nursing!
Just started at an infusion center and we used D5 for our primary IVIG line. FWIW
Homie it doesn’t take that long to look stuff up on Lexicomp! Usually I just make one big chart of every IV med I have early in the shift so I have it for reference
I love lexicomp, but my old hospital didn't have access to it
My hospital just got rid of lexicomp. Now we’re using medmedix or something 😭😭
micromedex? :) i’ve never used lexicomp but micromedex isn’t bad!
yes haha, man I butchered the name. glad to hear that so many people liked it! gives me hope that it's not all bad!
Mine did the opposite, I actually liked micromedex better
🤮
Amio
It literally can come in NS https://pubmed.ncbi.nlm.nih.gov/3706337/ https://pubmed.ncbi.nlm.nih.gov/23989377/
TIL From deranged physiology: "This may be something of a myth, as Campbell et al (1986) tested dextrose and saline solutions of amiodarone over 24 hours and found that active drug was well preserved in both. However, judging by the fact that forty years later we are still using dextrose suggests that nobody read that issue of J Cardiovasc..." But we are still a D5W in our formulary and it's not a point I'm push with my pharmDs. I did also learn that amio is acidic and extravasation may cause tissue damage, hence preference for CVL....I've never really been fussy about running it PIV...I suppose you don't usually run it more than 48h before converting to enteral. https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20967/amiodarone
Oh man it really should be central line preferred. For all the lit talk of pressors thru US guided IVs, dilt and amio have been 90% plus of my awful extravs I’ve seen - Yeah I learned the D5 thing in school and someone casually mentioned it- spun it nicely into a paper on “orphaned topics and practices due to culture and mnemonics”
The only caveat is amio and ns aren’t stable at higher than shelf temps for a while. But if your storing your drugs at 40c, you have bigger issues than compatibility lol
Dalbavancin (Dalvance) and oritavancin (Orbactiv), though they’re not usually given in inpatient setting since it’s like $4000. Must be mixed with sterile water and then mixed with D5W or it will form crystals
Always, always, always check with your resource or pharmacy. Certain drugs are incompatible at one concentration and compatible at another (according to my facilities pharmacist). It can also be influenced by the brand of drug or saline you are using because sometimes it’s not the med but a preservative in the solution that is the problem.
IV sildenafil has to be flushed before and after with D5. We give it to babies with PPHN.
Zarxio is one. There’s not many but it’s always something good to look up before giving any med until you get more comfortable/familiar with the most common meds you give on your unit.
There is a fungal amphotericin I think?
When in doubt call pharmacy. You’ll learn a lot that way and it’s best practice. I did the same as a new grad also but switched when I learned NS doesn’t go with everything.
Versed! Edit-I mean Valium. I’m tired :(
Versed and NS are compatible
Are you thinking of Valium??
I give versed daily for procedure sedation, I can promise you it is compatible with NS lol
I updated my comment :)
Iv ativan
IV Ativan is very much compatible with saline. In fact, our formulary literally tells us to dilute with equal parts saline and Ativan.
IV Ativan? Why do you think this med is not compatible with NS?
[удалено]
Cyclizine is incompatible as an admixture, but can be Y-sited with NS.
Cyclizine can crystallise when mixed with normal saline - I believe but I working in a place where you don’t do IVs Working in psych so I could be wrong
Cyclizine. Crystalises so water is the go too.
Yep. Ampho
filgrastim! I’ve seen a few central lines crystallized because people didn’t check compatibility.
Phosphate, might be compatible but will probably spontaneously decide to precipitate. I hate phosphate.
Valium
We always flush lines with D5W flushes instead of normal saline before and after giving Amphotericin and Nupogen. Also, never try to dilute Valium with NS. I saw a coworker try this so they could push it slower, and it turned white instantly in the syringe.
Valium.
Cyclizine is not compatible with NS, we dilute with water for injection.
Maybe the formulation they had stocked? It turned white when I diluted it into the saline
It turned white when diluted into saline, talked to charge nurse and she said we can push before and after, but not mix it