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.
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
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
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!
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!
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. :)
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. :)
stevierae
1,085 Posts
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)