dextrose and dilantin

[sweetieann]

I know dextrose and dilantin given together would/could crystallize the veins. My question is--say D5W was running into a patient and then dilantin IV was ordered. Since it could take like 20 minutes to push the Dilantin, say it was instead injected into NS and run as a piggyback over an hour. What would be done about the incompatibility of the D5W and dilantin? OR for any piggyback that was not compatible with the primary fluid for that matter (scenario: the piggyback line is connected at the Y-port on the primary line)? My thinking is that even though the piggyback would be hung above the primary and thus run in by itself (the primary would stop), when the primary starts up again there would be some piggyback residue in the line. I'm a student, btw:rolleyes: ANy feedback appreciated:)!

[hrtprncss]

It should either be mainlined, take out the dextrose main infusion, flushed then connect the dilantin. Or if you want to use it as a piggy back then prime a new saline bag and piggy back it. But if you're just giving a bolus then just use a mainline one. 1 gm in 20 minutes or 50 mg/min.

[papawjohn]

Hey Sweetie

Gosh that sounds good, doesn't it....

Anyhow, dilantin; however you put it in the IV line, first flush thoroughly with saline. Then you can give it at 50mg/min for a MONITORed Pt. Then flush thoroughly again with saline before resuming any Dextrose fluid. My usual method is to draw up two 10cc syringes of saline and a 10 or 20cc syringe of dilantin in saline. I stop the IV, flush the line, then give 1cc each 20 to 30 seconds til the dose is in. Then a final slow flush (slow because of course you are moving forward the dilantin still in the tubing).

You are going to be giving a very sclerosing med!!! It's gonna BURN!!! So dilute the dilantin as much as practical. I don't think spending 5 minutes or more doing this is time badly spent. You can 'pre-treat' the Pt's vein with an ice bag if you wish.

However you give it, you're going to be starting a new IV pretty soon. Dilantin just wipes out veins.

Best to ya

Papaw John

[Daytonite, BSN, RN]

Old IV Therapy nurse here. . .Dilantin crystalizes almost immediately upon contact with D5W. The resulting solution contains little bits of white, filament-like matter which you can see. Sometimes the solution is able to continue on down the drip chamber and through the the clear IV tubing making its way down the tubing toward the IV cannula. If things haven't yet clogged up within the IV tubing everything will stop infusing at the IV cannula hub since that filament-like matter clogs up the IV cannula and everything, generally, stops dead in it's tracks at that point. I've often been unable to save an IV clogged with this crystalized solution. If I have been lucky enough to save one of these clogged up IV's (it requires replacing all the IV tubing on the line and flushing the hell out of the newly unclogged IV cannula), it generally has to be changed soon because a phlebitis develops at the site of the IV cannula or in the vein just distal to it because of the irritation from the Dilantin solution and all the flushing with saline. In order for a significant amount of these Dilantin-Dextrose filaments to actually get into a vein, the IV cannula has to be of a very large bore.

In some of the hospitals I worked the nurses had a standing policy that required them to mix any IV push medication into 50 or 100cc of saline or D5W and allow it to drip over a 1 hour period (preferably on a pump). This dilutes a strong, irritating medication a bit to make it less corrosive in a patient's veins.

With dilantin mixed into a piggyback you either have to completely remove the IV line with D5W in it while the Dilantin admixture infuses, or clamp off the D5W line while the dilantin admixture is running. (I learned not to trust some types of roller clamps on IV lines. I used to put the rubber needle sheaths from IM tubex cartridges on the two blades of my hemostats and then used my hemostats to clamp IV tubing off while a piggyback infused.) In any case, you need to flush the point at which you are attaching the Dilantin admixture to the patients IV line with a fair amount of saline (5 to 10cc will suffice) before attaching and infusing the Dilantin. Similarly, you flush the point of attachment with 5 to 10cc of saline after you remove the line with dilantin admixture and reattach or restart the D5W infusion. That final flush of saline helps to move along any remaining Dilantin hanging around in the vein so it is cleared out before restarting the D5W.

You always "sandwich" any IV push medication between boluses of saline except, perhaps, during a code blue when time is a life-saving issue. Pull up a chair and put your watch with a second hand on it right in front of you so you can control how fast you inject the medication. With Dilantin 5 to 10cc of saline should be used. I would sometimes mix IV dilantin with a couple of cc's of saline in a 10cc syringe before giving the IV push.

By the way, when doing an IV push a larger volume syringe generates a lower pressure and is less likely to cause a vein to "blow" when it's contents are injected into a vein. So, it is always better to use a 10cc syringe rather than a 3cc syringe to push an IV medication. I know this is not always practical, especially with saline flushes, but for something like Dilantin I would take the extra effort to use a larger syringe because of the havoc this medication can create in the patient's vein.

Now, I know you're just chomping at the bit to get a chance to give this medication, aren't ya?

[NessaNurse]

wow! This reminds me of when I was a student. I had an RB on the floor who would do something to the effect of mixing dilantin with D5 or piggyback it rhough D5. She aksed me to give it like this too. I refused. She thought I was a wierdo but I told her why and she didnt really believe me. Oh well, after that the floor had an education sessionover it. I would take down the D5. Flush really well and then run the dilantin diuted and relatively slow. Also check qh for infiltration or IV problems, IV infiltrates from dilantin are nasty

[TiffyRN, BSN, PhD]

I'm happy to say that apparently I used to give IVP Dilantin very similarly to how Daytonite described. The floor I worked on had a policy that all IVP Dilantin was to be given through a free-flowing (or nearly so) line of NS. I would disconnect whatever current IV the patient had and connect the IV of NS (usually we strung up a 250ml bag and left it for other to push their Dilantin through). I also would dilute my Dilantin dose to 25mg/ml with saline in a 10ml syringe so I could accurately monitor my push rate then give the dilantin at 25mg/minute. Our policy only required 50mg/minute but patients usually complained too much of the pain (unless they were lucky enough to have a Central IV). I was so happy when the use of Cerebyx started becoming more popular (it's much easier on the veins and compatible with most IV solutions but apparently costs much more).

Thankfully now that I work with newborns I've never had to give Dilantin. Another thing is with infants we have these nifty things called syringe pumps with I would have LOVED when I worked med-surg. I've spent hours and hours at bedside slow pushing volatile meds. How I would have loved a syringe pump to accurately and safely administer Dilantin (or digoxin, or lasix or morphine).

[Daytonite, BSN, RN]

we have these nifty things called syringe pumps with I would have LOVED when I worked med-surg. I've spent hours and hours at bedside slow pushing volatile meds. How I would have loved a syringe pump to accurately and safely administer Dilantin (or digoxin, or lasix or morphine).

:yeahthat:

[sweetieann]

thanks for explaining so good, you should be a nursing instructor:)

[Daytonite, BSN, RN]

Why, thank you! Because I worked as an IV therapist I was able to observe and experience a lot connected with IV's. Pack this information away if you won't be using it immediately. You've gotten some real good replies on giving Dilantin. It's one of the odd medications that you have to be careful with.

I have also seen the results of what can happen when IV Dilantin infiltrates into the tissues. It is not pretty, believe me. I've heard of people having to have plastic surgery to correct the mess. The same kind of problems with infiltration also come up with IV Dopamine.

[caroladybelle, BSN, RN]

I have also seen the results of what can happen when IV Dilantin infiltrates into the tissues. It is not pretty, believe me. I've heard of people having to have plastic surgery to correct the mess. The same kind of problems with infiltration also come up with IV Dopamine.

Many places are phasing out IV Dilantin and using IV Cerebyx (fosphenytoin) instead. The drug is more compatible, can be pushed faster and with more safety, and causes less damage if it infitrates.