compartment syndrome-did I cause it?

[Lynn RN ER TX]

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 her IV (I was pretty busy w/ other pt's) she put a 20g in L wrist. Before doc had seen her I sent blood (drawn by other RN when IV started) for lab/blood cx. Also sent PD drainage for cx.

After doc saw pt no other labs ordered. Pt given Demerol/Phenergan for pain, flushed w/ saline before & after and meds were diluted in 10cc to ease the burn.

Labs came back - pt has peritonitis. Holding her as admit - waiting on room. Throughout day several doses Demerol/Phenergan given in same fashion as above. @ 1600 when pushing Demerol/Phenregan pt stated it burned. I stopped, asked her if it burned @ insertion site. She said "no, it burns all the way up my arm, the same as before". I flushed w/ 10cc of saline before continuing w/ meds to make sure no infiltration, then again flushing after. Site was not swollen nor any change in color.

About 30 minutes later pt c/o pain at IV site. Swelling noted. Saline lock was removed, hand eleveted on two pillows and hot wet towels wrapped around hand. Re-check approx q 5 min each time re-apply new hot wet towel. Within 30 min hand started to swell, appeared like venous congestion. MD notified - charge nurse notified. I checked radial and ulnar pulses w/ vascular doppler and checked pulse oximetry on each finger (all was normal)also motor sensory was normal. Within approx 10 min MD in room and plastic surgeon consulted. Plastics doc shows up within about twenty minutes, by this time hand looks like crap - swollen blue/purple - loosing sensation, pulses still strong, motor still intact. Decision to take to OR for fasciotomy. I gave my manager full report within twenty minutes of pt going to OR.

Next day I was called to meeting w/ administrative legal people - risk management - me and my manager. It was deemed a "Centinel Event" and we had a "Root Cause Analysis Meeting". Although this meeting was supposedly to "figure out what went wrong and prevent it from ever happening again", they were asking me things like "what is your experience, how many hours did you work that day, how many shifts in a row was this for you, what other type of pt's did you have that day, how busy was the ER?". It was a little intimidating and they nor I could come up with anything I could've done to prevent this - however my charting was picked to pieces. I chart a significant amount more than most of our ER nurses, I even make some of them chart more before they report off to me. Am I at risk here because of too little charted? Everything in this posting IS CHARTED.

[susanmary]

:)

[stevierae]

I've been following this thread. Some posts are good and others are high and mighty.

I'd like to say that while Phenergan burns when given IV, who knows if this is the actual culprit. It seems like the IV in the wrist (a lot of nerves there) could be the problem. When the IV was inserted it could have injured some nerve causing swelling etc... Just my two cents.

Actually, Zac, the more common injury from the scenario you suggest would be radial nerve palsy--not compartment syndrome.

I, for one, NEVER suggested that Phenergan caused the compartment syndrome written about in the original post. I simply saw the discussion about Phenergan via peripheral IV going on, and thought I would share some of the caveats against the practice.

I doubt that anyone has figured out for sure what caused the compartment syndrome. If indeed the hospital gets sued, (or any hospital in any IV case) it really will not matter what caused it.

Various theories will be offered and discounted, all kinds of experts brought in by both sides, and finally the case will settle with the money every hospital has set aside for defense of IV injuries.

The case, you see, will finally be called "Res Ipsa Loquitor"--"the thing speaks for itself."

Here's an example of a "Res Ipsa" IV case. Let's use Zac's scenario.The patient enters the hospital and, while there, sustains a radial nerve injury from multiple attempts at IV access in the "intern's vein" and, during those multiple attempts, the radial nerve got harpooned with an 18 G IV stylet, maybe more than once.

Swelling, pain, numbness and eventually wrist drop develop during her hospital stay. She files suit.

The case will be battled for a while, and finally someone will say what they should have said in the beginning: "This is what we know: This patient entered the hospital with normal range of motion and sensation in her left arm; she left with radial nerve palsy which, even with vigorous p.t., rehab and even surgery, is unlikely to be reversible. However it occurred, the hospital (as the source of deep pockets, as well as the employer of everyone who cared for the patient) is liable."

Both the defense and the plaintiff lawyers made money, the experts made money, the behind the scenes consultants made money, and the patient made money.

[stevierae]

With standards being set by who ever decides to set a standard and then not allow anyone but members be privy to the information is not right and leaves us all open to being held negligent.

I absolutely agree with this statement. It has been a pet peeve of mine for a long time that, while we as nurses are rigorously held to recommended TEXTBOOK "standards of care," we don't necessarily have access to those textbooks or authoritative resources--and are often expected to purchase them ourselves.

I am an operating room nurse and was practicing long before we ever HEARD the phrase "standard of care." We always just used our education, training, knowledge, experience and most importantly our gut instinct and common sense to deliver good patient care.

Unfortunately, nowadays, because of litigation and many other reasons, we are forced to practice "by the book" or risk getting sued. Everything is black or white; there are no gray areas.

I don't have my own current AORN Standards because they are far too expensive. I don't have the current INS standards, though I must refer to them frequently, both in nursing negligence cases and to do occasional clinical IV teaching. I refuse to buy either; instead, I go to the medical library of the neighborhood hospital. If they don't have what I need for the year I need it, I go to the big university medical center library here.

I think that nurses need to demand that their employers purchase the appropriate standards of care and most cited authoiritative resources for whatever their specialty areas are and keep them on their units, for easy access by everyone. It is, indeed, ludicrous to expect people to keep up with the most current recommended evidence based practices if they don't have easy access to them.

INS Standards should be available on any floor where patients have IVs--that is, everywhere.

[MrsWampthang, BSN, RN]

We are ordered to give phenergan all the time and I have seen nurses simply dilute and push it through a saline lock. I always push it slowly through a running IV as far up the tubing as I can get away from the IV site. Most of the time my patients don't report burning, but they still do sometimes.

I wonder what it would take to change this practice in my hospital? I found all of the points valid and information that I didn't know. Thanks to all who offered the information.

Pam

[SmilingBluEyes]

I am sure glad MY hospital made it against policy to push phenergan in any way in any peripheral line. If YOU MUST HAVE IV antiemetic, there are OTHER choices that are so much effective anyhow.

[zacarias, ASN, RN]

If any of you all are interested, here is an article from the journal Anesthesia and Analgesia that is very relevant to this topic.

Transient Compartment Syndrome of the Forearm After Attempted Radial Artery Cannulation

Qvist, Jesper MD; Peterfreund, Robert A. MD, PhD; Perlmutter, Gary S. MD

Departments of Anesthesia (Qvist, Peterfreund) and Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (Perlmutter).

Accepted for publication April 2, 1996.

Address correspondence and reprint requests to Jesper Qvist, MD, Department of Anesthesia, Massachusetts General Hospital, Fruit Street, Boston, MA 02114.

Radial artery cannulation for continuous intraoperative monitoring of arterial blood pressure is considered a safe procedure. One complication of arterial cannulation is hematoma formation at the time of insertion or removal of the catheter. Bleeding is usually self-limited or will stop with compression without significant sequelae, even in the anticoagulated patient. We describe a case of hematoma with a transient compartment syndrome of the forearm after attempts to cannulate the radial artery for intraoperative monitoring purposes.

Case Report

A 73-yr-old woman presented for right total hip replacement. Her past medical history was noteworthy for degenerative arthritis of major weight-bearing joints. She had undergone right total knee replacement surgery 2 yr previously and left total hip replacement 3 mo before the present admission.

Her mild hypertension was well controlled with spironolactone and hydrochlorothiazide. She volunteered a history of poor circulation in both hands with a tendency to easily suffer from very cold hands and fingers. She had been given a diagnosis of "modified Raynaud's phenomenon" but had never received treatment. There was no history of blood disorder or coagulopathy. Her only other medication was a low daily dose of aspirin, which she had stopped taking 7 days before admission.

At the preoperative visit, the patient reported that after the last operation her right forearm had become severely discolored (blue, and later yellow). A right radial artery catheter had been inserted successfully for that surgery. There had been no pain, change in sensation, or restriction of movement. The past medical history was otherwise unremarkable. The review of systems and physical examination were also unremarkable. An Allen's test was not reported. Preoperative evaluation also revealed normal blood chemistry values, a hematocrit of 32% after the donation of two units of autologous blood, and a platelet count of 355,000/mm3. Preoperative clotting studies were not obtained. As part of the preoperative regimen, the patient received dicoumarol (10 mg per os) on the night before surgery for venous thrombosis prophylaxis.

Radial artery pressure monitoring was chosen to supplement the routine monitoring. Skin analgesia over the left radial artery was achieved with 1% plain lidocaine using a 25-gauge needle. The first cannulation attempt failed because it was not possible to advance the 18-gauge Teflon catheter into the artery, although initial blood flow through the catheter was brisk. Several more cannulation attempts at the same site failed, after which pressure was applied for 3-4 min.

A second insertion site with a strong pulse was chosen 2-3 cm proximal to the first site. Similar problems were encountered, leading to several punctures through the same skin hole. Hematoma formation around the artery was observed. Further cannulation attempts were stopped and the puncture site was compressed, again for several minutes. The patient then complained of an unpleasant feeling of tightness in the forearm extending proximally to the elbow, primarily on the volar side (flexor muscle side). Inspection revealed no discoloration, but the tissues were very firm to the touch and the patient had great difficulty closing her fist. Examination by the orthopedic surgeons revealed: 1) equal right and left radial and ulnar pulses, both above and below insertion site, normal Allen's test, and similarly sluggish capillary responses in both hands, which felt very cold; 2) normal strength of finger and hand flexion and extension; 3) normal sensation to touch, proprioception, and two-point discrimination; 4) normal symmetric pulse oximetry values measured at the third finger, both with and without ulnar artery occlusion; and 5) marked pain on passive extension of digits and pain on palpation of the forearm.

Because of the increased tension in the forearm tissues, it was decided to measure the actual pressures in the forearm compartments before proceeding with the planned hip surgery. Using the inner metal needle of an 18-gauge intravenous cannula attached to a transducer at the level of puncture, left arm pressures were measured in both dorsal and volar tissue compartments at the level of the mid forearm and 3-4 cm from the elbow joint Table 1. Noninvasive blood pressure at this time was 179/89 mm Hg as measured by an automated oscillatory blood pressure cuff on the opposite arm.

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Table 1. Invasive Pressure Measurements

The forearm was covered with ice for 40 min to decrease the metabolism of the tissue threatened by hypoperfusion. Invasive pressure measurements were then repeated in the high-pressure compartments. The compartment pressures had decreased to 55 mm Hg; systemic noninvasive arterial pressure was unchanged.

Although pressures were still above normal, the patient had substantial relief of discomfort and muscle strength and sensation remained normal. It was decided to proceed with the hip surgery under epidural analgesia. This approach allowed us to examine for any neurologic deficit during the surgical procedure. The remaining surgical and anesthetic course were uneventful. There was no excessive surgical bleeding.

The patient's left forearm remained swollen for several days. The skin turned blue on the third postoperative day from wrist to elbow on the volar side. Postoperative values for prothrombin time were marginally increased on the first postoperative day: 12.6 s, corresponding to an International Normalized Ratio of 1.1. Thereafter, normal values were obtained. The bleeding time was 5 min, and the lowest platelet count recorded was 198,000/mm3 on postoperative day one.

The patient was discharged 5 days after surgery. The hand and arm were functioning normally, and she had no problems using her crutches. She was seen 2 wk after the surgery because pain had developed in the left forearm. Physical examination did not reveal any swelling or signs of neurological damage, and the pain subsided over the following week without treatment.

Discussion

Compartment syndrome after radial artery puncture in patients with only minor systemic disease has not been reported previously. Our patient had only wellcontrolled hypertension and a history suggestive of peripheral arterial disease, perhaps a mild form of Raynaud's phenomenon, for which she had never received therapy. Hyperreactivity of the radial artery may have contributed to the inability to cannulate the vessel. This in itself does not explain the excessive bleeding into the deep compartments of the forearm. Dicoumarol is routinely used for this type of surgery for thrombosis prophylaxis, and epidural catheters are routinely placed for these orthopedic procedures without prior measurement of the prothrombin time. The patient's International Normalized Ratio was normal on the first postoperative day, the prothrombin time being 12.6 seconds and the control value 11.5 seconds. Also, the intraoperative bleeding was considered normal for the procedure. Thus, there was no evidence of coagulopathy. We believe the patient had a compartment syndrome because direct pressure measurements revealed pressures in excess of or within 10 mm Hg of the diastolic blood pressure (see below). A compartment syndrome arises when increased pressure within a limited space restricts the circulation to that area followed by ischemia. Compartment syndromes of the forearm have become increasingly well recognized [1-3]. They are most commonly caused by trauma with and without fractures, especially after high-velocity injuries. Patients with decreased levels of consciousness and children are particularly prone to late diagnosis and may later develop Volkman's ischemic contracture with severe loss of function of the affected arm and hand [4,5]. Iatrogenic causes of forearm compartment syndromes include inadvertent injection of hypertonic saline for nerve blocks [6,7], faulty blood pressure cuffs [8], and attempts at cannulating veins and arteries of the arm in patients on systemic anticoagulants or patients treated with a thrombolytic drug [9,10].

The earliest sign of compartment syndrome is marked pain, often out of proportion to the extent of injury. Early physical signs of forearm compartment syndrome include a tense swollen compartment, pain with passive finger extension, and altered hand sensation [2]. Peripheral pulses and capillary flow are unreliable indicators of compartment status [3]. In line with this observation is the fact that pulse oximetry does not correlate with raised intracompartmental pressures and may show normal hemoglobin saturation values in the absence of peripheral pulses [11]. Changes in evoked sensory potentials and vibratory sensing are the earliest signs of increased compartment pressure as evidenced in animal and human experimental compartment syndromes [12,13].

The definitive diagnosis is made after direct measurements of intracompartmental pressures. Our patient experienced symptoms attributable to increased compartment pressure, and we obtained direct pressure measurements to support a diagnosis of compartment syndrome. Thus, we believe that compartment syndrome is another potential complication of failed arterial cannulation, even in the patient without coagulopathy.

The level of compartment pressure sufficient to cause ischemic damage to tissue depends on the perfusion pressure and the time elapsed to relief of the pressure. Experimental data have shown significant changes in somatosensory potentials as early as 45 minutes after increasing pressure to 30 mm Hg [12]. This is in accordance with earlier recommendations for decompression fasciotomies, which held that increased compartment pressure greater than 30 mm Hg will cause nerve damage. Damage will become permanent in 8 to 12 hours if not relieved. If the compartment pressure is greater than 40 mm Hg, a fasciotomy is usually performed immediately, and fasciotomy is indicated if the pressure remains between 30 and 40 mm Hg for longer than four hours [14]. However, experimental and clinical experience has shown that ischemia typically occurs at tissue pressures that are 10-30 mm Hg less than the diastolic pressure. Therefore, compartment pressure results should be interpreted not only as an absolute number but also in relation to the patient's diastolic blood pressure.

In the present case, the exact time of onset of compartment syndrome was known. Therefore, the surgeons elected not to perform immediate fasciotomies but to repeat measurements after 45 minutes. Although pressures were still increased, pressure (55 mm Hg) in relation to diastolic pressure (89 mm Hg) was now acceptable and the patient had substantial relief of discomfort, so we decided to proceed with the surgery with an alert patient, abstaining from further pressure measurements due to the satisfactory clinical findings.

Thus, in selected circumstances, conservative management of compartment syndrome may be indicated, especially when close monitoring of an alert patient is possible and there is objective evidence of rapid resolution.

We conclude that compartment syndrome is another potential complication of arterial cannulation, even in the uncomplicated patient. Surgeons, anesthesiologists, and intensive care physicians need to be alert for the possibility of a compartment syndrome, especially when the patient is unable to communicate with caregivers.

REFERENCES

1. Naidu SH, Heppenstall RB. Compartment syndrome of the forearm and hand. Hand Clin 1994;10:13-27. Library Holdings Bibliographic Links [Context Link]

2. Gelberman RH, Garfin SR, Hergenroeder PT, et al. Compartment syndromes of the forearm: diagnosis and treatment. Clin Orthop 1981;161:252-61. Library Holdings Bibliographic Links [Context Link]

3. Hamlin C. Compartment syndrome in the upper extremity. Emerg Med Clin North Am 1985;3:283-91. Library Holdings Bibliographic Links [Context Link]

4. Eaton RG, Green WT. Volkmann's ischemia. A volar compartment syndrome of the forearm. Clin Orthop 1975;113:58-64. Library Holdings Bibliographic Links [Context Link]

5. Brown RL, Greenhalgh DG, Kagan RJ, Warden GD. The adequacy of limb escharotomies-fasciotomies after referral to a major burn center. J Trauma 1994;37:916-20. Library Holdings Bibliographic Links [Context Link]

6. Mabee JR, Bostwick TL, Burke MK. Iatrogenic compartment syndrome from hypertonic saline injection in Bier block. J Emerg Med 1994;12:473-6. Library Holdings Bibliographic Links [Context Link]

7. Quigley JT, Popich GA, Lanz UB. Compartment syndrome of the forearm and hand: a case report. Clin Orthop 1981;161:247-51. Library Holdings Bibliographic Links [Context Link]

8. O'Neil D, Sheppard JE. Transient compartment syndrome of the forearm resulting from venous congestion from a tourniquet. J Hand Surg 1989;14:894-6. [Context Link]

9. Thomas WO, Harris CN, D'Amore TF, Parry SW. Bilateral forearm and hand compartment syndrome following thrombolysis for acute myocardial infarction: a case report. J Emerg Med 1994;12:467-72. Library Holdings Bibliographic Links [Context Link]

10. Halpern AA, Mochizuki R, Long CE 3d. Compartment syndrome of the forearm following radial-artery puncture in a patient treated with anticoagulants. J Bone Joint Surg 1978;60:1130-7. [Context Link]

11. Mars M, Hadley GP. Failure of pulse oximetry in the assessment of raised limb intracompartmental pressure. Injury 1994;25:379-81. Library Holdings Bibliographic Links [Context Link]

12. Present DA, Nainzedeh NK, Ben-Yishay A, Mazzara JT. The evaluation of compartmental syndromes using somatosensory evoked potentials in monkeys. Clin Orthop 1993;287:276-85. Library Holdings Bibliographic Links [Context Link]

13. Phillips JH, Mackinnon SE, Beatty SE, et al. Vibratory sensory testing in acute compartment syndromes: a clinical and experimental study. Plast Reconstr Surg 1987;79:796-801. Library Holdings Bibliographic Links [Context Link]

14. Porter JM, Taylor LM, Baur GM. Nonatherosclerotic vascular disease. In: Moore WS, ed. Vascular surgery: a comprehensive review. New York: Grune & Stratton, 1983;55-97. [Context Link]

15. Whitesides TE Jr, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975;113:43-51. Library Holdings Bibliographic Links

[stevierae]

If any of you all are interested, here is an article from the journal Anesthesia and Analgesia that is very relevant to this topic.

Transient Compartment Syndrome of the Forearm After Attempted Radial Artery Cannulation

Really great article--thanks for sharing--but let me just make one distinction, and it is meant to be educational, not argumentative--we can all learn from each other, new grads and old timers like me--

There is a huge difference between failed venipuncture (blowing the vein) and failed arterial puncture (blowing an artery.)

Since arterial blood is, well, arterial blood, and thus under high pressure, an extravasation of blood from the radial artery constitutes hemorrhage, not a slow ooze that will soon seal itself off, even without pressure, as a vein would.

Large amount of arterial blood extravastes, fills up the confined space--no method of escape--resultant compartment syndrome, unless a timely intervention of continuous direct pressure prevents the action in the first place--and that direct pressure would normally be over at least 15 minutes.

[nurturing_angel]

Reading this thread is scary! Its enough to make me want to leave nursing altogether. I feel like no matter what we do, we are playing russian roulette everytime we check in. I am beginning to think I no long want to take the chance of losing everything just to take care of people and help out along the way. Maybe I am just burned out more than I originally thought, but gosh, this thread is so depressing.

[stevierae]

Reading this thread is scary! Its enough to make me want to leave nursing altogether. I feel like no matter what we do, we are playing russian roulette everytime we check in. I am beginning to think I no long want to take the chance of losing everything just to take care of people and help out along the way. Maybe I am just burned out more than I originally thought, but gosh, this thread is so depressing.

Why do you find it depressing? There is a lot to be learned from it, as there is on any other nursing BB --people come together from different backgrounds, different perspectives, different ways of doing things, trained on different equipment.

In most areas of nursing, there is more than one way to approach patient care; not any one way is the be all and end all. From BBs like this, you can learn new techniques and discard others--take what works for you and discard the rest.

I can't tell you how many times over the past 30 years I have watched a 22 year old OR tech do something and thought to myself, "THAT is a really good idea--that's the way I'M doing it from now on." and I change the way I had been doing it --and I may change it again, the next time I see a young tech do something innovative.

What's sad is the people who resist change or new ideas--like the OR nurses I have worked with who have never worked anywhere else but the hospital affilited with the nurisng school that they did their clinicals at, 40 years ago, and who know only one way of doing things--the way they've always done it.

[lady_jezebel]

Isn't there a possibility of acute compartment syndrome from a venous puncture when a pt is on anticoagulation therapy?

[stevierae]

Isn't there a possibility of acute compartment syndrome from a venous puncture when a pt is on anticoagulation therapy?

Sure, because they bleed more and the leak may not stop spontaneously. Same thing with a nosebleed when a patient is on anticoagulation therapy--nosebleed may not stop sponataneously as it would with a "normal" person. But we were just talking in general terms, about essentially healthy patients.

Compartment syndrome can even occur with a simple IV infiltration if the volume is sufficient. Imagine if 1000 cc. of fluid entered the hand and had no means of escaping, or if simple interventions (heat, elevation, pressure) failed to keep the swelling down by allowing it to reabsorb.

An MD colleague is currently working on a newborn compartment syndome that resulted in loss of a foot. The IV infiltrated into the infant's foot and caused the compartment syndrome. He believes that less than 50 cc infiltrated, but over a very short time, and was not recognized until after the surgery was over and the drapes pulled off. This is another "Res Ipsa Loquitor" case --this infant was born, went to surgery because of pyloric stenosis, and an IV in his foot infiltrated while it was under the surgical drapes, unnoticed.

(He had 3 other IVs running for access, one of which was a central line; this foot one was just at a KVO rate--however, the

Now his parents will have to see him take his first steps with only one foot. An accident; yes, but a preventable one--why didn't they just convert that unnecessary IV to a saline lock and d'c the fluid infusion?

I am almost certain the defense will point to IV pump malfunction--but a smart plaintiff attorney will point out that an IV not in use does not need to be on a pump--in fact, it shouldn't have had fluid running, period.

[IMustBeCrazy]

Thanks for the education on this drug Stevierae. I am a student and I actually dug up my Pharm info as well as pulled my 2004 Drug book to look this over. Surprisingly, nothing was cited in any of the current 2004 resources that I have about the problem that you have outlined. This is also the first time I had heard about the resources of the INS.

However, there is something about this situation rubs me the wrong way. Please don't misunderstand, I am not killing the messenger here, I understand your reasons for posting and I am glad that you did. I have also worked in the legal environment in a previous job, nursing is my 2nd career.

Having said that, the part that I (and I think others) are having a problem with is the 'reasonable and prudent nurse' jury instruction that you referred to. If I have completed my med checks having referred to current 2004 drug information and consulted pharmacy, I would have a problem with being sued for not being 'reasonable and prudent'. To be honest, this Phenergan situation smacks of one of those 'gray areas' that certain lawyers and their minions are jumping the bandwagon on because they were able cash in (you did reference someone completing an expensive house addition, remember?) by 'outmaneuvering' a defense attorney not doing their job by explaining in detail exactly what 'reasonable and prudent' means, or a naive jury that doesn't understand the myriad of medical resources, journals, private 'for profit' and 'not for profit' societies that are all proposing contraindicating theories of care. I have found that for every legal expert there is an equal opposing expert...it's all part of the legal 'game'. Another thing that is bothersome is that in order for this nurse to have 'covered' herself, it seems she should have been a member of a society that charges dues to members to be able to have access to the information proposed in trial, so these standards are not available to every 'reasonable and prudent nurse' by design and are in effect, self-limiting.

The disclaimer printed inside the cover of the 2004 Drug book I have states:

"The clinical procedure described and recommended in this publication are based on research and consultation with nursing, medical, pharmaceutical, and legal authorities. To the best of our knowledge, these procedures reflect currently accepted practice; nevertheless, they can't be considered absolute and universal recommendations. For individual application, all recommendations must be considered in light of the patient's clinical condition and, before the administration of new or infrequently used drugs, in light of the latest package-insert information..."

Not having access to a Phenergan package insert, what does it say about IV admin? Because ultimately it should be listed there. Manufacturers have a legal duty to list every untoward effect caused by their product. Let's suppose that IV admin is contraindicated on the insert. Would a 'reasonable and prudent nurse' even have access to this insert? My guess would be no.

Again I want to thank you for the information you have shared. But I think you can see from the above that no matter how diligent we think we are, this can easily be skewed in a court of law.