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.
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.
You make some really, really good points. I am going to ask my colleagues who were experts on those Phenergan via peripheral IV cases if the defendants involved WERE INFUSION NURSES--and therefore were held to the standards of care laid out by INS for infusion nurses, but chose to ignore them, or were not current with the literature, as is required of them.
It is entirely possible that med surg nurses would not be held to these standards, just exactly for the reasons you cited, since those standards were not ones that were generally readily available to them--in fact, not being infusion nurses, they did not even know of the existence of an organization called INS. All one can do to deliver reasonable and prudent care in some situations is to use the resources that are available TO THEM--AT THAT TIME. That may not have included the standards established by INS.
Now, critical care nurses I WOULD think would be held to those standards--since they have intensivists and anesthesiologists on their unit that could educate them about potential dangers of Phenergan via peripheral IV, and, if need be, insert a central line if it was necessary. On the med surg floors, nurses don't have that luxury.
Critical care nurses also have received extensive training about extravasation and atidotes for drugs such as Dopamine, Norepinephrine, etc. and as such would be expected to know how to handle an extravasation in a timely fashion. To me, this would include emergency room nurses.
I will check with my infusion nurse colleagues and post back on the topic when I find out. Thank you for bringing up these excellent questions.
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.
I promised I would get back to you with my colleague's thoughts. She has been a CRNI since 1988, a member of INS since 1985, and is past president of AVA. (Association for Vascular Access, I believe it stands for.) She teaches IV access world wide, consults for various IV manufactures and infusion companies, and is clinically active as an infusion nurse, running a remicade infusion clinic and inserting various high-tech infusion devices (PICCS, etc.) She is also frequently called upon as an expert in IV cases, both defense and plaintiff.
Her name is Kelli Rosenthal, and her website, for any and all interested in reading and learning all about vascular access, (as well as other nursing issues) is http://www.ResourceNurse.com. Here are her comments:
"All nurses performing infusion therapy are held to the INS Standards. Standards are a bare-bones, set in stone, this is the line in the sand I won't cross, test of what constitutes safe and prudent care by a professional nurse. AVA does not write standards, only position papers, because we're a multidisciplinary organization.
If a nurse doesn't know the pH, the pharmacy has that information available, and most drug information is now online. I did a search for Phenergan, got a lot of hits, and they all say that extravasation can cause serious injury. A nurse should not administer a medication that she or he does not know everything they need to know about it - especially if giving it IV, because of the lack of ability to recall or reverse it.
Even if they don't know or have access to the standards, a reasonably prudent nurse does know the principle that pain signals tissue damage. If you know it hurts, why would you knowingly damage the patient's tissue? I've made that point in several cases, and it's always worked.
I agree that all standards should be accessible. INS' feeling is that hospitals should write their P&Ps to reflect their standards, so they shouldn't have to give them away. "
My own (stevierae) final thought: (I sound like Jerry Springer, LOL!)
"Pain Signals Tissue Damage." That's all I need to know, and what guides my own practice. I think the "reasonable and prudent nurse" in any practice setting is capable of doing the same. If medication given through a peripheral IV is painful to a patient, then for heaven's sake--something is wrong! If the peripheral IV is patent, then it does not take a rocket scientist to conclude that the problem is the drug.
I promised I would get back to you with my colleague's thoughts. She has been a CRNI since 1988, a member of INS since 1985, and is past president of AVA. (Association for Vascular Access, I believe it stands for.) She teaches IV access world wide, consults for various IV manufactures and infusion companies, and is clinically active as an infusion nurse, running a remicade infusion clinic and inserting various high-tech infusion devices (PICCS, etc.) She is also frequently called upon as an expert in IV cases, both defense and plaintiff. Here are her comments:
"All nurses performing infusion therapy are held to the INS Standards. Standards are a bare-bones, set in stone, this is the line in the sand I won't cross, test of what constitutes safe and prudent care by a professional nurse. AVA does not write standards, only position papers, because we're a multidisciplinary organization.
If a nurse doesn't know the pH, the pharmacy has that information available, and most drug information is now online. I did a search for Phenergan, got a lot of hits, and they all say that extravasation can cause serious injury. A nurse should not administer a medication that she or he does not know everything they need to know about it - especially if giving it IV, because of the lack of ability to recall or reverse it.
Even if they don't know or have access to the standards, a reasonably prudent nurse does know the principle that pain signals tissue damage. If you know it hurts, why would you knowingly damage the patient's tissue? I've made that point in several cases, and it's always worked.
I agree that all standards should be accessible. INS' feeling is that hospitals should write their P&Ps to reflect their standards, so they shouldn't have to give them away. "
My own (stevierae) final thought: (I sound like Jerry Springer, LOL!)
"Pain Signals Tissue Damage." That's all I need to know, and what guides my own practice. I think the "reasonable and prudent nurse" in any practice setting is capable of doing the same. If medication given through a peripheral IV is painful to a patient, then for heaven's sake--something is wrong! If the peripheral IV is patent, then it does not take a rocket scientist to conclude that the problem is the drug.
Potassium given IV is painful also, do you refuse to give potassium IV?
Potassium given IV is painful also, do you refuse to give potassium IV?
I am unaware of any instance in which KCl is indicated via IV push or rapid infusion--enlighten me.
It isgenerally mixed in a large volume of fluid (typically the peripheral 1L IV) and given over an extended period. I have never heard of a patient c/o burning after KCl administration given in this manner.
Stevie- Thank you very much for this information. As a soon to be new grad., I sometimes focus on the complicated things and forget the obvious, basic stuff. I think we all know that burning is indicative of tissue damage but in a clinical situation may not realize it. But now those words are burned into my memory.
OP-how are things going? Although I'm sure you don't feel wonderful about what happened to your patient, just know that you have probably educated many others to potential problems of this drug and any other IV drug.
I am unaware of any instance in which KCl is indicated via IV push or rapid infusion--enlighten me.
It isgenerally mixed in a large volume of fluid (typically the peripheral 1L IV) and given over an extended period. I have never heard of a patient c/o burning after KCl administration given in this manner.
I am not talking about push or rapid infusion, I am refering to it (10meq) being mixed in 100ml (which is standard for k riders in my experience in more than one hospital) and infused over one hour, and I, and fellow nurses, have known of many patients who complain of burning.
Even if they don't know or have access to the standards, a reasonably prudent nurse does know the principle that pain signals tissue damage. If you know it hurts, why would you knowingly damage the patient's tissue? I've made that point in several cases, and it's always worked.
I agree 100% that if something hurts it's a no brainer. But some folks may, due to body chemistry etc., not feel this. And as long as I'm checking for the standard infiltration signs per P&P and things are going looking good/going well, I don't see how this could possibly be construed as not 'reasonable and prudent'.
Furthermore (and I'm trying to educate myself on this aspect) according to whose authority I should be accountable to the above named standards? Where can I find a reference to this material other than on the INS website?
I am not talking about push or rapid infusion, I am refering to it (10meq) being mixed in 100ml (which is standard for k riders in my experience in more than one hospital) and infused over one hour, and I, and fellow nurses, have known of many patients who complain of burning.
Maybe you should suggest to the powers that be that the practice of diluting in it 100 ml. routinely results in patients complaining of burning? Maybe you could start with Risk Management and perhaps you and fellow RNs could sit in on a Pharmacy committee meeting and share your joint experiences? Maybe the practice would be changed, resulting in better and safer patient care, attributable to your being pro-active and advocating for your patients?
Why not suggest it be diluted in a 250 cc. (or even 500cc) piggyback, and see if it makes a difference? Could it hurt?
I am lucky in that in most of the operating rooms where I have worked, we mix our own piggybacks. No one specifies a volume; we are expected to use our nursing experience; if we did ask, they would most probably say 250 cc. for 10 mEq. For 20 to 40 mEq, it goes in the 1L peripheral (main) IV, but only after induction.
I am not talking about push or rapid infusion, I am refering to it (10meq) being mixed in 100ml (which is standard for k riders in my experience in more than one hospital) and infused over one hour, and I, and fellow nurses, have known of many patients who complain of burning.
Again, it's a matter of first ascertaining to make certain that the IV site is patent, and then as others have posted, increasing the diluent and slowing the infusion. For some patients, they don't tolerate peripheral IV K+ and if possible, as an alternative, it's given po. It's a matter of evaluating the situation and working with the physicians, pharmacy to ensure that the medication is given correctly or if available, an acceptable alternative is given in its place. Potassium, although it burns, differs in damage than vessicants if extrasated.
Arg! Just wrote my post then got kicked off! Sorry if this shows up twice. Does anyone know where I can find the complete list of vessicants (with tx for infiltration, etc.)? From this forum I've realized how important it is to be in the know about these drugs. Does anyone care to list some from memory? Thanks in advance!
Again, it's a matter of first ascertaining to make certain that the IV site is patent, and then as others have posted, increasing the diluent and slowing the infusion. For some patients, they don't tolerate peripheral IV K+ and if possible, as an alternative, it's given po. It's a matter of evaluating the situation and working with the physicians, pharmacy to ensure that the medication is given correctly or if available, an acceptable alternative is given in its place. Potassium, although it burns, differs in damage than vessicants if extrasated.
I know all that, of course, I was just asking the poster a simple question, "do you refuse to give potassium IV?".
If one is using burning as an indication there are other drugs that burn as well regardless of the dilution or time factor.
These patients wander thru the ER doors .....and when they enter they enter with all their comorbities in hand.The pt had CRF and was on dialysis right?Poor circulatory problems too I bet?Poor perfusion?Did you manufacure the drug Phenagran?No..no you didnt.It strips the intima layer of the vein...it is damaging.there is no way to avoid it.you can dilute it, give it slow etc.....but it is still a vessicant irritating drug.You see this not only with Phenagran and chemo drugs but even antibiotics like amikacin.Its like running gasoline thru the veins.....you might dilute the gas ....but it is still gasoline....and the pt still had numerous problems.none of these are anyones Fault!If they want to attach blame then blame the MD.He shouldve had/ordered the pt to have a PICC placed since he ordered the vessicant drug.At most hospitals its protocol for a Picc to be placed for drugs like Amikacin and yes even phenagran.He couldve ordered Anzmet or Zofran ya know.It is NO ONES FAULT!
stevierae
1,085 Posts
You make some really, really good points. I am going to ask my colleagues who were experts on those Phenergan via peripheral IV cases if the defendants involved WERE INFUSION NURSES--and therefore were held to the standards of care laid out by INS for infusion nurses, but chose to ignore them, or were not current with the literature, as is required of them.
It is entirely possible that med surg nurses would not be held to these standards, just exactly for the reasons you cited, since those standards were not ones that were generally readily available to them--in fact, not being infusion nurses, they did not even know of the existence of an organization called INS. All one can do to deliver reasonable and prudent care in some situations is to use the resources that are available TO THEM--AT THAT TIME. That may not have included the standards established by INS.
Now, critical care nurses I WOULD think would be held to those standards--since they have intensivists and anesthesiologists on their unit that could educate them about potential dangers of Phenergan via peripheral IV, and, if need be, insert a central line if it was necessary. On the med surg floors, nurses don't have that luxury.
Critical care nurses also have received extensive training about extravasation and atidotes for drugs such as Dopamine, Norepinephrine, etc. and as such would be expected to know how to handle an extravasation in a timely fashion. To me, this would include emergency room nurses.
I will check with my infusion nurse colleagues and post back on the topic when I find out. Thank you for bringing up these excellent questions.