compartment syndrome-did I cause it? - page 3

Adult female pt came to ER c/o severe abd pain. Was triaged for same in ER day before - left R/T long wait time. Hx CRF, currently doing PD @ home, after assessing her I asked another nurse to start... Read More

  1. by   RedSox33RN
    Just chiming in here, for no other reason than to say I wish I was at one of the institutions that no longer gave Phenergan IV when I was hospitalized 2x (3 and 4 days respectively) last December for a stomach "bug" that made my diabetes hard to control. I was given the Demerol/Phenergan cocktail round the clock. Even diluted, Phenergan is like dumping acid into veins - a form of torture in my book. After going through 11 IV sites in 4 days because of it, I begged them to give it to me IM, or not at all. Even IM it can be bad (I had a spot on my arm that was numb for months because of it), but no where near as bad as IV.
  2. by   mattsmom81
    Quote from moia
    Try to remember that you followed established protocal, you investigated the patients complaints promptly and intervened. You were given doctors orders which you followed, you had a patent IV and gave the medication as directed. Sadly bad things can happen, every drug and every procedure we do has risks.
    I know it is absolutely heartbreaking when you are trying to help someone and the treatment causes problems but it is the risk we take with every med we give and every procedure we do.
    Try to participate in the investigation as much as possible and hopefully some good answers will be discovered, it is quite possible there was no true error but a medication reaction that caused a series of physical reactions that finally resulted in compartment syndrome. Sadly we can't always protect our patients from this kind of reaction but we can certainly begin to work on a system that decreases the risks as much as we possibly can.
    You are involved in an important process and your experience and your patients experience can be a truly sad event that had an important outcome for your coworkers and for all nurses to learn from.
    Great post, ITA !
  3. by   stevierae
    I will never, ever ever give Phenergan IV, no matter if it is ordered via central line; no matter if it is ordered by an anesthesiologist; no matter who orders it. It's my license on the line, and I know the drug, and I know my responsibility as patient advocate.

    When Inapsine (Droperidol) went out of vogue for anti-nausea, there was a trend toward ordering Phernergan IV. There are people who think they can get away with it if they dilute it and give it slow IV push or IVPB, or that it's OK via PICC or IJ--BUT THE pH OF THE DRUG REMAINS THE SAME regardless of how it is diluted!!!


    INS standards are very, very clear about what drugs can or cannot be given IV due to pH. Phenergan is one that is contraindicated.

    I am a legal nurse consultant as well as an operating room nurse. A fellow LNC, who is an IV nurse, (CRNI) stated that she paid for the (very expensive) addition on her house by reviewing and testifying on Phenergan IV cases.

    All an attorney needs to do is blow up the applicable INS standard addressing ph and display it next to the pH info about Phenergan for the jury to see. It is said that the average jury typically has an average 6th grade education and attention span, but that one is a no-brainer.

    "I gave it that way because the doctor ordered it that way?" another no brainer. "Our institution commonly gives it this way?" Still another no-brainer.

    Nurses have autonomy and are accountable for their own actions in a court of law. Doctor as "captain of the ship" doesn't hold up anywhere. National published standards ALWAYS override local or institutional policy and procedure. Just because your institution says it's OK does NOT make it so.

    Think about what "a reasonable and prudent nurse under the same or similar circumstances" would do, and act accordingly, or even MORE reasonably and prudently, as defined by your additional experience or skill level or certification, as what I just said constitues MINIMUM standard of care.

    Even a new grad who is up on her nursing school pharmacology would question whether it is "reasonable and prudent" to give Phenergan IV, as it is likely that she learned all the reasons in nursing school that it is contraindicated. Someone demands you give it that way? Show them the INS standards and refuse to do it.

    There is absolutely no reason to give Phenergan IV. I have been a nurse and done multiple travel OR assignements for 23 years, and did clinical IV teaching, again in various states. Before that, I was a Navy corpsman. We have always, in my practice ANYWHERE, given it IM--or, in infants, via rectal suppository.
    Last edit by stevierae on Apr 24, '04
  4. by   Spidey's mom
    Amazing information . . . I'm like Tweety and give it frequently IV, especially in the ER.

    Never had a patient complain about burning though. Never had a bad outcome.

    I'll be sure to talk with our pharmacist on Monday about it.

    Thanks.

    steph
  5. by   jaimealmostRN
    Stevierae, what is INS? Where would one find a copy of it? In my 'Clinical Drug Therapy' 6th ed. by A.Abrams and in 'Davis' Drug Guide for Nurses' 8th ed. by J. Deglin it doesn't really discuss the negative effects mentioned on this thread. Davis' says,"Administer each 25mg slowly,over at least 1 min. Rapid administration may produce a transient fall in blood pressure...doses should not exceed a concentration of 25mg/ml." Aggg! This is quite scarry b/c I always check the s/e of my drugs b/f giving them and if I had never read this thread I would not have known about the phlebitis/compartment syndrome risk. :uhoh21:
  6. by   stevierae
    Quote from jaimealmostRN
    Stevierae, what is INS? Where would one find a copy of it? In my 'Clinical Drug Therapy' 6th ed. by A.Abrams and in 'Davis' Drug Guide for Nurses' 8th ed. by J. Deglin it doesn't really discuss the negative effects mentioned on this thread. Davis' says,"Administer each 25mg slowly,over at least 1 min. Rapid administration may produce a transient fall in blood pressure...doses should not exceed a concentration of 25mg/ml." Aggg! This is quite scarry b/c I always check the s/e of my drugs b/f giving them and if I had never read this thread I would not have known about the phlebitis/compartment syndrome risk. :uhoh21:
    INS stands for "Infusion Nurses" Society." They make the guidelines and standards for intravenous administration of drugs and placement of infusion devices (PICCS, peripheral IVs etc.) You should be able to find their website online by typing in "Infusion Nurses' Society" or you could post on the Intravenous Nursing section of this BB.

    Here is a bit that I saved from a legal nurse posting on this issue on a different listserv a while back; the person who posted it is also a CRNI (Certified Registered Infusion Nurse) who is a past President of the Infusion Nurses' Society. If anybody doubts the validity of this info this, or wants more info first hand, IM me and I will forward your email to her, or get permission to give you her email address.

    Interesting comments about risks associated with phenergan
    administration.

    I have reviewed > 20 cases involving extravasation of this drug in the ER setting; in the majority of these cases the drug had minimal dilution with saline; all cases resulted in need for skin grafting.

    A key factor often confronted was the lack of following proper extravasation
    protocols when the extravasation event occurred which led to heightened
    morbidity.

    I have also had several cases in which the phenergan was administered intra-arterially resulting in amputation.

    There seems to be some confusion as to the application of INS standards regarding to phenergan administration.

    According to standard #43 (Site selection): "Therapies not appropriated for peripheral-short catheters include continuous vesicant chemotherapy, PN formulae exceeding 10% dextrose and/or 5% protein, solutions and/or medications with a pH less than 5 or greater than 9, andsolutions and/or
    medications with osmolarity greater than 500 mOsml/L".

    According to Gahart, Intravenous Medications: phenergan's pH is in the range of 4-5.5 which does create the dilemma of what is actual pH of the
    phenergan being administered (note that dilution will not change the pH of the
    drug)
    Last edit by stevierae on Apr 24, '04
  7. by   fab4fan
    The website is www.ins1.org

    Sorry, I would have just linked it, but the link function isn't working for me.
  8. by   fab4fan
    Cripes, now it did work. Oh well.
  9. by   jaimealmostRN
    Thanks guys for the information. These are the types of things I was hoping to read about on the "tips for new grad" type threads. I'm going check that website and then bring it up for discussion in class on tuesday!
  10. by   teeituptom
    Quote from SmilingBluEyes
    sorry I misunderstood the post. my apologies, Tom! :stone :imbar
    Smooches back and peace
  11. by   Tweety
    Quote from stevielynn
    Amazing information . . . I'm like Tweety and give it frequently IV, especially in the ER.

    Never had a patient complain about burning though. Never had a bad outcome.

    I'll be sure to talk with our pharmacist on Monday about it.

    Thanks.

    steph


    Yes very information indeed. Thanks stevierae. Our computerized med sheets give instructions for giving it IV. I kind of disagree about "what a prudent nurse would do", so if I ever get in trouble, then I'm taking down the pharmacy, the docs, and the hospital with me.

    But I'm going to contact the nursing/pharmacy committee on this one. Sounds like we definately need to change our policy and quit giving it. Thank goodness with demerol going out of favor, we don't give it all that often anymore.

    Vesicants are going to extravasate, that's a fact. People are then going to sue and blame the nurse. That's another sad fact. Sigh...the joys of having a license.
  12. by   SmilingBluEyes
    Phenegan SUCKS IV. When I had my daughter,they gave it to me IVP, diluted in 10cc of saline, and it hurt all the way up to my armpit. Not too long after my IV infiltrated and the whole area became so red and raw, I was convinced way back then, IV phenergan was no goood. I can attest, giving phenergan, even diluted IVP hurts like a bear.

    Now I need to correct myself from an earlier post, if I may.

    I should NOT BE saying necessarily this OP "caused" compartment syndrome with phenergan IV. I agree with "prmenurse", the OP needs to get involved in the follow up of this case and all of us need to learn more. It could have been a combination of factors that led to this problem, and I bet it was. I am very, very sorry I mis-stepped in my first post saying it was the phenergan that caused this. I don't know for sure what did, and I believe strongly we need get out of the "fingerpointing" habit nursing and medicine are into, (myself included here), and get past it----And LEARN from these things.

    I hope the OP will check back in and let us know what the findings are so we all can learn here. I am sorry for any assignment of blame on my part. The blame and ego's are not important, learning and doing better in the future for patients surely IS.
    Last edit by SmilingBluEyes on Apr 25, '04
  13. by   rollingstone
    Sorry this happened to you. As you said the pt. had no visible veins but, man, I hate those wrist IV's.

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