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.

[rmprn]

Tom, you are crackin' me up!!! We also give phenergan IV where I work, and I agree with everything you have said. There are risks associated with every drug, no matter how it's administered. And OUR Phenergan vials say "for IV OR DEEP IM USE" so the drug company can go down with me along with the doctor and the hospital!!

[stevierae]

I like attacks

Not an attack. I do not attack or flame anyone. Also, the info was NOT "from the allnurses board" but from the INS Standards--Standard # 43 to be exact, which I quoted verbatim earlier. The book of INS Standards is the authoritative resource that will be quoted in court.

Why risk known complications?

Extravasation of Phenergan that ends in sloughing and perhaps amputation of a limb is not a simple untoward side effect. It is a known and dangerous complication that has resulted in patients losing their limbs and resulted in substantial jury verdicts--therefore, there is case precedent that makes another such incident a "slam-dunk."

The hospital who chooses to ignore published evidence based practice standards might as just well take out their corporate checkbook, and ask the injured party to "fill in the amount."

The potential problem with Phenergan via peripheral IV is due, once again,to the pH of the drug, and no amount of dilution can change the pH.

I believe that Phenergan can possibly--POSSIBLY--be given via central line, just like chemo, as it is, after all, going into the superior vena cava. One cannot compare the superior vena cava to a peripheral vein, however. I have never known a single anesthesiologist who is comfortable giving it IV, even through a central line. We give it IM, if we give it at all. Zofran is the drug of choice in most operating rooms. There is also a new trend toward giving 8mg. Decadron slow IV push pre-op, as studies have shown that that amount helps alleviate post-op nausea.

I am hardly one of those "by the book" nurses. I also am not one that does things simply "because the doctor ordered it" or because "that's the way we've always done it" or "I've been giving it that way for 30 years." Whatever. Do it however you'd like; you will, anyway.

[cannoli]

It's given IV where I work also.

[RNPATL, DNP, RN]

I also am not one that does things simply "because the doctor ordered it" or because "that's the way we've always done it" or "I've been giving it that way for 30 years." Whatever. Do it however you'd like; you will, anyway.

I think stevierae makes an excellent point. We must make sure that our practice, as nurses, is based on sound research. We need to be flexible to change our practice standards based on the latest and newest research that promotes the highest quality of care.

Simply going about business because thats the way we have always done it, it dangerous in our profession today. As professional nurses, it is our obligation to be aware of current evidenced based practice standards and understand how to implmenet these standards of care into our individual practice as nurses. For me, knowing the latest research and how I can improve my care for my patients is very important. I also think it elevates the profession when nurses promote the use of research, and practice according to new research findings.

[Tweety, BSN, RN]

The hospital who chooses to ignore published evidence based practice standards might as just well take out their corporate checkbook, and ask the injured party to "fill in the amount."

But stevierae couldn't this be said of all vesicants? Should we ban them all, what about Dilantin and the host of other chemo agents around, haven't they all had the ultimate price of a limb or two over the years?

You make it sound like limbs are falling off right and left. Honestly, while I've heard of chemo problems, and we had one big problem this past decade where I work with Dilantin, but never have I heard of loss of limb or even any problem with IV phenergan.

So the question being, is it all that common? Should be do away with all drugs that have untoward side effects and lawsuits?

I'm not all coldhearted, if it were my patient, or loved one loosing the limb, then one loss of limb is too many.

[stevierae]

But stevierae couldn't this be said of all vesicants? Should we ban them all, what about Dilantin and the host of other chemo agents around, haven't they all had the ultimate price of a limb or two over the years?

You make it sound like limbs are falling off right and left. Honestly, while I've heard of chemo problems, and we had one big problem this past decade where I work with Dilantin, but never have I heard of loss of limb or even any problem with IV phenergan.

So the question being, is it all that common? Should be do away with all drugs that have untoward side effects and lawsuits?

I'm not all coldhearted, if it were my patient, or loved one loosing the limb, then one loss of limb is too many.

I think if you absolutely must give a vesicant via peripheral IV, (as opposed to PICC, implanted port or IJ central line,) you had better make da**ed sure that IV is patent and that you have Wydase (or whatever the appropriate antidote is to give ON HAND, and use it THEN AND THERE to hopefully prevent sloughing if extavasation occurs.

But, again, I just don't see why one would take the risk with giving Phenergan via peripheral IV, when there are alternatives. Why not advocate for the patient, by saying, "You know, INS has some pretty impressive evidence as to why Phenergan should not be given via peripheral IV. I would be far more comfortable with using Decadron or Zofran. Or, if you INSIST on Phenergan, why don't we just give it IM?"

Or what's so wrong with saying, "I'm sorry, I am not comfortable giving Phenergan via peripheral IV, and I will not do so?" We are, after all, first and foremost the patient's advocates. I would hate to think a patient suffered ANY injury, however minute, if there was an alternative to what caused it in the first place. Why should a patient even be subjected to burning and pain? Doesn't that tell you that that medication is doing damage to that peripheral vein?

I have not seen Dilantin given via peripheral IV in many years; ditto with Phenobarb. I think there are kinder, gentler anticonvulsants nowadays.

[Indy, LPN, LVN]

Well, I had a nice specific reply posted and the board ate it. Next try:

The only one of my books ON my shelf that had any suggestion of a mention of problems with promethazine IV use, was my drug book. It lists "venous thrombosis at injection site" as an adverse reaction. It says to not give the 50mg/ml dose IV, but apparently the 25mg/ml dose is ok IV as long as you take longer than a minute to give it. I take it this means no bolus injections in a line unless you sit there and time it to take greater than a minute.

My background on IV meds to date is, nothing formal. I'm a first year student, and first years in my program don't give IV meds. We do look up all the drugs our patient is on, and we look for signs of infiltration, and pay attention to what the nurses and/or clinical instructors do with the IV meds, but we can't mess with them yet.

The question I have is, what exact authority does INS Standards of Care book have on a local RN say, in Georgia? Is it common for different organizations to publish "standards of care" that may or may not affect you where you work? I'll be asking my clinical instructor tomorrow after class this same exact question, and looking up the hospital's policy/procedure manual on friday if I have time during clinical. But this really intrigued me.

So far, in our course we've been taught that the individual state sets the standards of care for that state, and that the hospital's policy and procedure manual should reflect this. If it conflicts, point it out to the physician and hopefully he will do something else. If not, the nursing supervisor should back you up. If your're asked by both the hospital, and the MD to do something that's outside of or against your standards of care, you follow your state's standards because that's who issued your license. I have never even heard of INS before, so that's where I'm confused.

Thanks for all the wonderful discussion though!

-Indy

[Repat]

Great questions, Indy! I want to know, too.

[stevierae]

Great questions, Indy! I want to know, too.

INS Standards are national.

[Gldngrl]

Stevierae-Any chance of getting me access to those specific INS standards? When I accessed the site, I could not get info unless I became a member and I'm interested in bringing this information to our PhD. PM if you'd like. Thank you.

[stevierae]

Stevierae-Any chance of getting me access to those specific INS standards? When I accessed the site, I could not get info unless I became a member and I'm interested in bringing this information to our PhD. PM if you'd like. Thank you.

Unfortunately, you have to purchase the book--it is about $45. Your medical library should have it, however, or be able to get it; or, if your hospital has an in-house or home infusion department, or an IV team, or a chemo unit or outpatient clinic, they should have the current issue.

I quoted Standard # 43 in a previous post (post # 32, page 4.) If you scroll back to that post, it addresses drug pH and why drugs above and below a certain pH should not be given via peripheral IV. I then added the comments of a legal nurse consultant colleague of mine, who is a past president of INS, and remains clinically active as an infusion nurse.

[berry]

As with everything we do there is a risk an IM injection is a risk, starting the iv is a risk, the patient lying in hte bed is a risk Phenergan IV is an acceptable order does it burn yes, is there a potential for harm yes, but does it work yes, I use it daily in the ER 5-15 times a day most of the docs I work with order 12.5 iv only had one issue ever come and it was a site in a foot but she had several drugs iv and developed superficial thrombophlebitis. I continue to use give it iv and if called in court My lawyer would aslo present that the drug manfac. only gives a ph that could or could not be inside INS ranges but I acted IAW with hospital standards, IAW with the drug company standards, IAW any drug book I have ever looked in.