Phenergan IV changes in policy - page 4

Have your hospitals recently changed their policy for IV Phenergan? Just this week I noticed that we now have to try 6.25mg first then 12.5mg, it has to be diluted in 20ml and given over 15 minutes.... Read More

  1. by   JessicRN
    We have not changed any of our policies regarding phenergan it is given 25mg IVP there is no amount how to dilute it. I questioned it and even refused to give it as the pt is a drug addict and the only IV he had was in his thumb. The supervisor came down and told me to give it as there is no change here. I did luckily convince the doctor to decrease it to 6.5 but I was told if I refused again I would be written up
  2. by   CritterLover
    Quote from all4schwa
    we spike a liter bag with a luer lock and draw saline that way, i automatically grab a 12ml and dilute everything.
    we mostly use anzemet, does it cause the same problems?
    and, if phenergan is so irritating to the veins, why can it be given im?


    no, anzemet/zofran do not cause the same problems. they are not considered to be vesicants or irritants.

    im is a better route for most (not all) irritating meds. why? because the big muscle can tolerate it. it may burn, but you arn't damaging the muscle tissue. think about all of the burning, irritating antibiotics that are given im. plus all of the meds that are given safely im, but have to be given via the z-track method, so that the subq tissues arn't harmed.

    some meds can't be given im -- due to kinetic factors; or other factors, like heparin -- giving heparin im would cause local bleeding/hematoma.
  3. by   General E. Speaking, RN
    I wish we gave more Zofran. Phenergan is irritating. We have guidelines about diluting with NS that print up on our MARs. However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning. They change it in the doctor's order and write per Executive Medical Committee (or something). Pharmacy also changes every Demerol order to an equivalent Morphine dose (unless they are allergic). The only way around it is if the doc writes "do not substitute". Yep, it ticks the docs off, but most of them are used to it now. Some of our surgeons will only order Phenergan IM.
  4. by   GardenDove
    Hi, I'm at work, and my little email did the trick. My manager forwarded it to pharmacy and there was reminder spiel on an IV phenergan order I have tonight saying " To prevent rare instance of tissue necrosis: Dilute in 5-10 ml of saline: inject into a running IV (if possible) using the port ruthest from the patient's vein. (Max IV push dose 25 mg)"
    Last edit by GardenDove on Feb 14, '07
  5. by   nursemike
    Quote from GardenDove
    Hi, I'm at work, and my little email did the trick. My manager forwarded it to pharmacy and there was reminder spiel on an IV phenergan order I have tonight saying " To prevent rare instance of tissue necrosis: Dilute in 5-10 ml of saline: inject into a running IV (if possible) using the port ruthest from the patient's vein. (Max IV push dose 25 mg)"
    That is so cool--to see results that soon! Good for you and your manager.

    We've had a lot of education on phenergan, lately, too. We do give it IV, and I've never had a pt complain of it burning--I dilute it and push it slow. Real slow. But reading this thread, I'm thinking it'd be better to set up a bag of NS--even a 100ml bag--to run it with.

    A little off-topic, perhaps, we've had a lot of concern over IV dilantin. Last year we had what I assume was reported as a sentinal event--patient supposedly lost hand over IV dilantin. I can't verify that, but I did see the necrotic hand. Very sad, and scary, because we push dilantin a lot.

    I felt bad when I learned that a lot of more experienced nurses were routinely diluting dilantin. All I'd ever seen was push it very slowly in a good site and flush thoroughly, so that's how I did it. Since this incident, we've had inservices and been taught do not dilute dilantin. But the rational was that diluting it didn't change the pH--which, I think, is clearly wrong. If you dilute HCl, you change it's pH. And it's supposedly okay to give through a running IV, if compatible, which seems like dilution, to me. Anyway, I was glad I'd been doing it right, after all, and I've never had a pt complain of burning with it, either.
    So, does anyone happen to know why we shouldn't dilute dilantin? My best guess was maybe a risk of precipitation, but my drug guide doesn't say.
  6. by   Roy Fokker
    Quote from kriso
    I wish we gave more Zofran. Phenergan is irritating.
    I agree...

    ... but for some of my post op patients - Droperidol doesn't work. Granisetron doesn't work. Ondansetron doesn't work.

    But Phenergan does.

    Quote from kriso
    However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning. They change it in the doctor's order and write per Executive Medical Committee (or something). The only way around it is if the doc writes "do not substitute". Yep, it ticks the docs off, but most of them are used to it now. Some of our surgeons will only order Phenergan IM.
    Our pharmacy auto-subs Kytril (Granisetron) for Zofran.

    I personally like Droperidol - though the way we stock it on the floors is pretty stupid (usual dosage is 0.625mg - 1.25 mg... but out ampules on the floor are 2.5mg/2ml! It's kinda wasteful drawing up 0.25 mls per ampule and throwing the rest away! )
  7. by   meandragonbrett
    Quote from kriso
    However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning.
    Why is the hospital worried about it being expensive? This is insane. I was recently in the hospital and I was getting Zofran and Phenergan like crazy. I'd have been highly upset if the pharmacy told me I could have only had the zofran QDay. Who cares if it was intended for cancer patients if it works for other patients. Geez. The only thing our pharmacy changes is any orders written for Prevacid get changed to Protonix IV.
  8. by   Dooney121
    I have seen Pt's have to get amputated hands due to giving IV Phenergan have to make sure IV site is good.
  9. by   CritterLover
    Quote from gardendove
    i hadn't heard about not using prefilled syringes to dilute. do you have a rationale for that? i've been using them lately because it's faster than drawing up saline. i'll eject unneeded saline and carefully draw up the correct amount of med, such as ativan. i've found that convenient and thought it would be more sterile. i'll just add a needle to draw up the med.

    if you want to add something to a bag of saline, there is a port where you can do that, you just draw up the med and inject the proper dosage into the saline bag, usually a 50 or 100 cc bag. then put on a medication added label.


    i do the same thing.

    however, the ismp newsletter this month had a big article in it talking about why this shouldn't be done.

    their argument is that since the pre-filled syringes are labeled with the drug/concentration, once you add a med to it, the label is no longer correct. even if you add a label to the syringe, it could fall off, i guess.

    i have all of the ismp newsletters emailed to me at work, and have often thought that they are a little "over the top" with some of their safety concerns. at times it seems as though they don't give nurses any credit for having any brainpower whatsoever.

    but then of course a patient died from an 8 gram loading dose of dilantin, and now i wonder if some nurses do have any brainpower at all. :uhoh21:

    ismp link: http://www.ismp.org/nursingarticles/list.htm
    Last edit by CritterLover on Feb 25, '07 : Reason: ismp link
  10. by   GardenDove
    Critter lover, that edict sounds like it was issued by someone who spends their day behind a desk dissecting data not working at the bedside. It's totally ridiculous. By the time you give the med and throw away the syringe, what does it matter how the syringe was labeled? How idiotic.
    Last edit by GardenDove on Feb 25, '07
  11. by   GeminiTwinRN
    We have been seeing many many more orders for Kytril for nausea where I work than phenergan. The problem is, the patients ask for phenergan by name, and they are convinced that Kytril doesn't make them "feel" the same way. In other words, the euphoria or high isn't experienced by them.

    It's a dilemma, that's for sure. I always, always dilute in a 10cc prefilled syringe. I draw up the phenergan with a filtered straw, then attach a needle to squirt it into 9-9 1/2 cc of the saline. Then add the blunt, and off we go.

    Also, I'm in the habit of adding the orage label to ANY syringe that has med in it. That way, I have my flush syringe ready to go (blunt already on it) with no label, and the med syringe labeled. If I'm only giving one syringe of med, I don't write what med is in it, the orange label is enough to remind me which is which.

    I've never heard of not adding meds to the pre-fills. We use them constantly!
  12. by   PANurseRN1
    Quote from kriso
    I wish we gave more Zofran. Phenergan is irritating. We have guidelines about diluting with NS that print up on our MARs. However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning. They change it in the doctor's order and write per Executive Medical Committee (or something). Pharmacy also changes every Demerol order to an equivalent Morphine dose (unless they are allergic). The only way around it is if the doc writes "do not substitute". Yep, it ticks the docs off, but most of them are used to it now. Some of our surgeons will only order Phenergan IM.
    Zofran is available in generic form. We use it all the time for intra-op and post-op nausea. Initially, it was used primarily for chemo when it first was released, but it can be used for a cariety of indications.
  13. by   P_RN
    How about I make a plaster model of the gigantisauric phlebitis in my right forearm? It's as hard as a ROCK and painful as all get out. I tried filming it but no luck. Feel free to come over. Oh did I mention this happened in SEPT 06?

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