[espritjolieRN]

I gave IV phenergan diluted slow push a lot as well. It was in the process of being phased out when I left the floor though. Don't worry about it, you're fine.

We use needle systems in our clinic too - I prefer needleless but it's not that big of a deal. In the clinic you usually have one patient you're focusing on and one drug being given. Not like the floor where you're rushing from one patient to another and one med to another using one syringe after another. The risk is not nearly as high for us.

[NRSKarenRN]

From the pharmacy experts @ Institute for Safe Medication Practices:

Action needed to prevent serious tissue injury with IV promethazine

Problem: Promethazine (PHENERGAN) injection is a commonly used product that possesses antihistamine, sedative, anti-motion sickness, and antiemetic effects. The drug is also a known vesicant which is highly caustic to the intima of blood vessels and surrounding tissue. Formulated with phenol, promethazine has a pH between 4 and 5.5. Although deep intramuscular injection into a large muscle is the preferred par-enteral route of administration, product labeling states that the drug may be given by slow IV push, which is how it is typically given in most hospitals. However, due to the frequency of severe, tragic, local injuries after infiltration or inadvertent intra-arterial injection, ISMP recommends that the FDA reexamine the product labeling and consider eliminating the IV route of administration.

Severe tissue damage can occur regardless of the route of parenteral administration, although intravenous and inadvertent intra-arterial or subcutaneous administration results in more significant complications, including: burning, erythema, pain, swelling, severe spasm of vessels, thrombophlebitis, venous thrombosis, phlebitis, nerve damage, paralysis, abscess, tissue necrosis, and gangrene. Sometimes surgical intervention has been required, including fasciotomy, skin graft, and even amputation....

...Safe Practice Recommendations: Along with the manufacturer recommendations, the following strategies should be considered to prevent or minimize tissue damage when giving IV promethazine.

Limit concentration. Since 25 mg/mL is the highest concentration of promethazine that can be given IV, stock only this concentration (not the 50 mg/mL concentration).

Limit the dose. Consider 6.25 to 12.5 mg of promethazine as the starting IV dose, especially for elderly patients. Hospitals have reported that these smaller doses have proven quite effective.

Dilute the drug. Require further dilution of the 25 mg/mL strength to reduce vesicant effects and enable slow administration. For example, dilute the drug in 10 to 20 mL of normal saline if it will be administered via a running IV, or prepare the medication in minibags containing normal saline if there is time for pharmacy to dispense them as needed for individual patients. (Trissel confirms that promethazine is physically compatible when diluted in normal saline, with little or no drug loss in 24 hours at 21 degrees C in the dark, when prepared in glass, PVC, and polyethylene-lined laminated containers [Handbook on Injectable Drugs, 13th edition. ASHP, Bethesda, MD; 2005:1266].) Extravasation can also be recognized more quickly when promethazine is diluted than if the drug is given in a smaller volume.

Use large patent veins. Give the medication only through a large-bore vein (preferably via a central venous access site, but absolutely no hand or wrist veins). Check patency of the access site before administration. Note: according to the package insert, aspiration of dark blood does not preclude intra-arterial placement of the needle because blood can become discolored upon contact with promethazine. Use of syringes with rigid plungers or small bore needles might obscure typical arterial backflow if this is relied upon alone.

Inject into the furthest port. Administer IV promethazine through a running IV line at the port furthest from the patient’s vein.

Administer slowly. Consider administering IV promethazine over 10-15 minutes. ...

[suanna]

We used to push it constantly- and it made me nuts!!!! It's very hard on the veins, it's so sedative that I often wonder if you wouldn't be safer pushing 2-4mg of versed. The "bad reactions" are rare but EVERY patient gets lethargic, somnolent, with respiratory depression-those are "normal responses" to phenergan. I have often wondered if the only reason people thought it worked is because they were so gorked they didn't now they were nauseous. Before there were other options out there it was the best way to stop uncontroled N/V, but Zofran and Kytril have been around for long enough to have a proven track record. My hospital used to insist on phenergan as the drug of choice without a specific order of why it wasn't used instead of zofran/kytril. They admitted it was a $ issue. The docs threw enough fits that we are at least seeing a 50/50split. Hopefully, in the future, phenergan will be a intervention of last resort.

[marikat534]

We can only give 12.5mg IV per pharmacy protocol at my hospital. It is a pain the ass, I'd rather just pull up and give IM personally, seems to be more effective and stays with patient longer.

[ERNURSE158]

Can't give Phenergan IV???? I can't imagine life in the ER without IV phenergan. I mean...what good would PO be when the pt is projectile vomiting? I realize there are alternatives like Zofran, Reglan and Compazine...but nothing beats a good dose of sleepytime phenergan. Its true that it can be a bad thing, but if you assess the IV before you give it...and make sure its in the vein, You should be fine, I've even seen some nurses mix 25mg of Phenergan in 50ml IV bag of NS and let it run in.....I mix mine in 10cc NS like you did and I rarely have issues, some patient complain of a burning sensation, but if they do I typically add more saline or turn up the line so its diluted more.

[GrumpyRN63]

LOVE Phenergan, been giving it IV for 20 yrs, back in the day pts were ordered 25mg IV q4hr ATC X 48 hrs post op. Those were the days, never, ever had IV issues, still give it, usually 12.5 IV in 10cc on secondary, love how it snows 'em, great drug when all else fails

[10MG-IV]

Originally Posted by GrumpyRN63

LOVE Phenergan, been giving it IV for 20 yrs, back in the day pts were ordered 25mg IV q4hr ATC X 48 hrs post op. Those were the days, never, ever had IV issues, still give it, usually 12.5 IV in 10cc on secondary, love how it snows 'em, great drug when all else
fails

I will be the "Phenergan Nurse" what a specialty... although, for those retching Eggheads that change admin / delivery rules on drugs we love, I would have to give it rectally. Do you have to remove that foil for it to be effective????

[suni]

I have seen reactions to Phenergan IV from venous irritation to an area that required debridment. I hate to push but always dilute it, push slowly and usually also apply a warm compress to the site prior to and after the push.
THis drug is nasty. I did try to dilute it in 50cc of NSS and hang it as a mini bag however this is not recommended because if it infilitrates you are not there to see it, I only did that once and stayed in the room with the patient the entire time.

[Tait]

I got IV Phen once for a bout of viral gastroenteritis. I got a warm vein and then went totally loopy . I was talking to imaginary people and then falling asleep, but man it sure made me feel a lot better.

I mix in 10 and push nice and slow, assessing the patient for discomfort at all times. I have never had it perscribed for a patient much over the age of 55, but I can imagine it would blow the heck out of those 70+ veins.

I do prefer Zofran for my patients, gives them relief while letting them maintain thier consciousness.

[Kthale81]

Originally Posted by P_RN

Needle systems are illegal.....aren't they? I thoguht it was law by now. What compoany tubing are you using, surely then make an adapter.

I wished that type of tubing was illegal. I cannot count how many times I have went into a room and realized that I needed a blunt needle or one of those alligator clips. It is so annoying. I prefer the luer lock system, which those annoying little blunts and clips will be only a memory.

Re: phenergan.... I have known it to be given IV/IM/PO/IVPB