IV Phenergan and Toradol "Push"

Specialties Emergency

Published

Just thought I would bring a recent experience up for discussion:

29 May I end up in ER w/24 hours of extreme chills (long sleeve T-shirt, PJs, 2 blankets, quilt and down sleeping bag), intermittent, transient bone and joint pain, nausea and vomiting. I was given an IV set near the base of the thumb for fluids and then an IV "push" of phenergan and toradol at the site of the IV set rather than up the line where it would have been somewhat diluted. As a 30 year Crohn's disease patient I have had PLENTY of IV and IM phenergan and demerol w/o any discomfort or problems. But this one BURNED and HURT! The nurse continued the "push" and explained that it was the phenergan. I didn't really believe this given my previous experiences and assumed it was really the toradol as that was my first experience with it. The pain and burning only lasted a few minutes after the "push".

I had no swelling of the hand or arm, no pain, no redness for several days. Long enough that I never even thought of the IV push when I began with a bruised type feeling on the inside of the arm just above the wrist and the outside of the arm 1/2 below the elbow. Several days after that I did notice a hard stretch of vein about 3/4" long 1/2 way below the elbow on the outside of the arm. Later a "bump" at the wrist, still later another 3/4" hard stretch of vein just above and a little to the outside of the bump. And then a 1/2" hard spot in the vein below the base of the thumb at the wrist. It finally occured to me that this was probably the result of the IV push but since there was no redness, no swelling, no tenderness unless I kept poking the areas I didn't bother seeing a doctor about it. (Heaven knows I see him enough as it is, bless his heart!).

21 July the "bump" at the wrist turned red and was tender. Hot compresses did nothing for it that evening nor the next morning. My family doctor isn't in the office on Fridays and I figured the ER IV push was the cause so I went to ER. I was told it was "just" superficial thrombophlebits that could take as much as 6 months to resolve and was about to be released (which was ok with me as long as the doctors weren't concerned). But the "lead" ER doctor came in, first time I had seen her, and she said she would feel more comfortable ordering a venous ultrasound before I was released as she had had 2 STs go "sour" on her in the previous 3 months. I didn't have a problem with that so of course I agreed. What the heck, she was the doctor.

Ha! Turns out I had a deep vein thrombosis in the axillary vein in that upper arm! You could have floored me!! I ended up being admitted and given IV heparin drip and oral coumadin. Upon release 3 days later I had to agree to daily blood draws which was a cheap price to pay to be released from the hospital since I didn't feel sick and didnt hurt.

I've since been reading up on STs and DVT and realize my part in letting things go so far. However, I've found quite a bit of controversey on IV phenergan (and also demerol). The Infusion Nurses Society Standard # 43 specifically states phenergan should NOT be given IV due to its PH and potential for harm.

Frankly, given my experience thru the years and the blessing that IV and IM phenergan (and demerol) has been I would hate to see its use be discontinued. However, this was the first and only time phenergan was ever administered IV that close to the IV set instead of up the line where it gets diluted w/the IV fluids.

I'd be interested in your thoughts and experiences on this event and the use and method of administering IV phenergan. Mind you, my mother worked at this hospital all the while I was growing up, other than Mayo Clinic it is the only hospital I have ever gone to (altho we have another in town) and I've been volunteering here for several years in Endoscopy or Messenger Service. I'm not looking to cause any trouble and I know my ER nurse from previous encounters in the cafeteria and elsewhere at the hospital and he is a fine and conscientious nurse. He was marvelous when my brother in law was brought in with an AAA.

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Specializes in ER/ICU/STICU.

I'm sorry to hear about your experience. To answer your question, we give IV phenrgren close to the site. Most of the time we give it to patients that have no IV fluids running, just a heplock. I know patients experience pain because it burns going in and then I just flush it with saline flush. I have never had a patient c/o burning with the toradol. Good luck and I hope you are getting better.

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I'm sorry to hear about your experience. To answer your question, we give IV phenrgren close to the site. Most of the time we give it to patients that have no IV fluids running, just a heplock. I know patients experience pain because it burns going in and then I just flush it with saline flush. I have never had a patient c/o burning with the toradol. Good luck and I hope you are getting better.

Thank you, but I hope that you will reconsider giving IV phenergan close to the site and via heplock or with just a flush if there is burning. There is quite a discussion about this on another nursing forum and several articles on STs caused by IV phenergan, some even given higher up the line. One has to take risk vs benefit into consideration, of course, but certainly giving the phenergan higher up the line is not an inconvenience for staff. My experience is no where near as unusual as you would think according to literature. And I know reliable websites from "junk" sites.

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I agree that phenergain iv is a nasty drug so I always dilute it with 10ml of NS before giving it either through a saline lock or an IV with fluids running. I also give it very slowly. I haven't had anyone tell me it caused burning using this method, and I don't know of anyone who has developed complications (of course, I work in the ER, and mostly we never hear what happens after patients leave us).

Toradol can not be mixed with any other medications. Is there a possibility that this happened? That the meds could have been given too close together without enough flush between them? Just a thought.

Good luck on your recovery.

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Specializes in Cath Lab, OR, CPHN/SN, ER.
I agree that phenergain iv is a nasty drug so I always dilute it with 10ml of NS before giving it either through a saline lock or an IV with fluids running. I also give it very slowly. I haven't had anyone tell me it caused burning using this method, and I don't know of anyone who has developed complications (of course, I work in the ER, and mostly we never hear what happens after patients leave us).

Good luck on your recovery.

Agreed. I dilute mine. My preceptor was good about telling me "this drug burns, dilute it!". -andrea

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Specializes in ER/ICU/STICU.
I agree that phenergain iv is a nasty drug so I always dilute it with 10ml of NS before giving it either through a saline lock or an IV with fluids running.

I like that idea, I think I'm going to start doing that. Perhaps I can get other nurses started on that as well. In my dpt we just give the phenergin IV push with a NS flush.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

You will stir up BIG controversy here, I am afraid......we have gone round and round about it before on these boards. By corporate policy (with some darn good reason, I think--based on some good evidence Phenergan with it's pH of like 1.9, does harm to veins) we are not allowed to give Phenergan IV, diluted or otherwise, to anyone at my hospital. I believe the IV Nurse's Association also stated some place it should never be given IV too.....but I am not a member, so I am just reaching here. Anyhow, where I work for over a year now.....

Phenergan must be IM or PO or not at all----we use other drugs more often anyhow.

Phenergan issue aside, am so sorry for all you have been thru. You have my sympathy; it sounds like a horrible time! I hope you do recover fully.

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Just thought I would bring a recent experience up for discussion:

29 May I end up in ER w/24 hours of extreme chills (long sleeve T-shirt, PJs, 2 blankets, quilt and down sleeping bag), intermittent, transient bone and joint pain, nausea and vomiting. I was given an IV set near the base of the thumb for fluids and then an IV "push" of phenergan and toradol at the site of the IV set rather than up the line where it would have been somewhat diluted. As a 30 year Crohn's disease patient I have had PLENTY of IV and IM phenergan and demerol w/o any discomfort or problems. But this one BURNED and HURT! The nurse continued the "push" and explained that it was the phenergan. I didn't really believe this given my previous experiences and assumed it was really the toradol as that was my first experience with it. The pain and burning only lasted a few minutes after the "push".

I had no swelling of the hand or arm, no pain, no redness for several days. Long enough that I never even thought of the IV push when I began with a bruised type feeling on the inside of the arm just above the wrist and the outside of the arm 1/2 below the elbow. Several days after that I did notice a hard stretch of vein about 3/4" long 1/2 way below the elbow on the outside of the arm. Later a "bump" at the wrist, still later another 3/4" hard stretch of vein just above and a little to the outside of the bump. And then a 1/2" hard spot in the vein below the base of the thumb at the wrist. It finally occured to me that this was probably the result of the IV push but since there was no redness, no swelling, no tenderness unless I kept poking the areas I didn't bother seeing a doctor about it. (Heaven knows I see him enough as it is, bless his heart!).

21 July the "bump" at the wrist turned red and was tender. Hot compresses did nothing for it that evening nor the next morning. My family doctor isn't in the office on Fridays and I figured the ER IV push was the cause so I went to ER. I was told it was "just" superficial thrombophlebits that could take as much as 6 months to resolve and was about to be released (which was ok with me as long as the doctors weren't concerned). But the "lead" ER doctor came in, first time I had seen her, and she said she would feel more comfortable ordering a venous ultrasound before I was released as she had had 2 STs go "sour" on her in the previous 3 months. I didn't have a problem with that so of course I agreed. What the heck, she was the doctor.

Ha! Turns out I had a deep vein thrombosis in the axillary vein in that upper arm! You could have floored me!! I ended up being admitted and given IV heparin drip and oral coumadin. Upon release 3 days later I had to agree to daily blood draws which was a cheap price to pay to be released from the hospital since I didn't feel sick and didnt hurt.

I've since been reading up on STs and DVT and realize my part in letting things go so far. However, I've found quite a bit of controversey on IV phenergan (and also demerol). The Infusion Nurses Society Standard # 43 specifically states phenergan should NOT be given IV due to its PH and potential for harm.

Frankly, given my experience thru the years and the blessing that IV and IM phenergan (and demerol) has been I would hate to see its use be discontinued. However, this was the first and only time phenergan was ever administered IV that close to the IV set instead of up the line where it gets diluted w/the IV fluids.

I'd be interested in your thoughts and experiences on this event and the use and method of administering IV phenergan. Mind you, my mother worked at this hospital all the while I was growing up, other than Mayo Clinic it is the only hospital I have ever gone to (altho we have another in town) and I've been volunteering here for several years in Endoscopy or Messenger Service. I'm not looking to cause any trouble and I know my ER nurse from previous encounters in the cafeteria and elsewhere at the hospital and he is a fine and conscientious nurse. He was marvelous when my brother in law was brought in with an AAA.

I have been a recipient of IV phenergan that was not diluted and it is very painful. When administering phenergan (and IV Benadryl for that matter) I allways dilute with at least 10cc NS, push it slowly, and higher up in the line if a line is avaliable if the pt only has a heplock I will further dilute to avoid hurting the patient.

0 Votes
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Agreed. I dilute mine. My preceptor was good about telling me "this drug burns, dilute it!". -andrea
it does hurt like hell---I have been on the receiving end of phenergan IV, and IT SUCKS. there are FAR better choices than Phenergan anyhow.

It's very good practice to dilute most IV drugs, anyhow, esp in a Saline lock---and to flush well afterward, thoroughly.

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You will stir up BIG controversy here, I am afraid......we have gone round and round about it before on these boards. By corporate policy (with some darn good reason, I think--based on some good evidence Phenergan with it's pH of like 1.9, does harm to veins) we are not allowed to give Phenergan IV, diluted or otherwise, to anyone at my hospital. I believe the IV Nurse's Association also stated some place it should never be given IV too.....but I am not a member, so I am just reaching here. Anyhow, where I work for over a year now.....

Phenergan must be IM or PO or not at all----we use other drugs more often anyhow.

Phenergan issue aside, am so sorry for all you have been thru. You have my sympathy; it sounds like a horrible time! I hope you do recover fully.

There is a great thread about this subject with lots of advice and actually controvery, since everyone seems to do it differently. I wish I knew how to access it - maybe just search for "phenergan". It is a long long thread.

I'll just repeat here what I said there and that is that we use phenergan IV all the time, diluted and given at a higher port and never through a saline lock. Our pharmacist says it is an "off" use of phenergan and up to the doc to decide. We use it in the ER all the time. I've never ever had a patient complain of pain and never had any negative follow-ups.

steph

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
There is a great thread about this subject with lots of advice and actually controvery, since everyone seems to do it differently. I wish I knew how to access it - maybe just search for "phenergan". It is a long long thread.

I'll just repeat here what I said there and that is that we use phenergan IV all the time, diluted and given at a higher port and never through a saline lock. Our pharmacist says it is an "off" use of phenergan and up to the doc to decide. We use it in the ER all the time. I've never ever had a patient complain of pain and never had any negative follow-ups.

steph

I hear you; but I really believe in a few years, standard of practice will disallow IV use of phenergan. I would bet on it.
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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

here ya go Steph: (prior thread)

https://allnurses.com/forums/archive/index.php/t-23554.html

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