compartment syndrome-did I cause it?

Nurses General Nursing

Published

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.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Sounds like you did a good job. I've given IV phenergan countless times without incident. I hate doing it, same as I hate giving IV dilantin, but our institution has no policy against it, and we have docs that still order it. I'm sorry this happened to you.

About the review, I'm sure after interviewing you they are fine with their skills. They naturally just need to know if your competent to remain on their staff, or if they can blame you, since this is a potential lawsuit and they are assessing their risk.

Also as was said the purpose is really process improvement. Maybe the end result will be policies against giving these drugs IV, which would be a good thing. We've had several good policies comes out of these kinds of events. (But you can't convince me that they are also trying to cover their butt, and maybe fry the nurse if they could, for a potential lawsuit.)

But don't feel that it's your fault.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
read the post againg blueeyes

It dont say that

sorry I misunderstood the post. my apologies, Tom! :stone :imbar

Specializes in Emergency Dept, M/S.

Just chiming in here, for no other reason than to say I wish I was at one of the institutions that no longer gave Phenergan IV when I was hospitalized 2x (3 and 4 days respectively) last December for a stomach "bug" that made my diabetes hard to control. I was given the Demerol/Phenergan cocktail round the clock. Even diluted, Phenergan is like dumping acid into veins - a form of torture in my book. After going through 11 IV sites in 4 days because of it, I begged them to give it to me IM, or not at all. Even IM it can be bad (I had a spot on my arm that was numb for months because of it), but no where near as bad as IV.

Specializes in Emergency Dept, M/S.

Just chiming in here, for no other reason than to say I wish I was at one of the institutions that no longer gave Phenergan IV when I was hospitalized 2x (3 and 4 days respectively) last December for a stomach "bug" that made my diabetes hard to control. I was given the Demerol/Phenergan cocktail round the clock. Even diluted, Phenergan is like dumping acid into veins - a form of torture in my book. After going through 11 IV sites in 4 days because of it, I begged them to give it to me IM, or not at all. Even IM it can be bad (I had a spot on my arm that was numb for months because of it), but no where near as bad as IV.

Try to remember that you followed established protocal, you investigated the patients complaints promptly and intervened. You were given doctors orders which you followed, you had a patent IV and gave the medication as directed. Sadly bad things can happen, every drug and every procedure we do has risks.

I know it is absolutely heartbreaking when you are trying to help someone and the treatment causes problems but it is the risk we take with every med we give and every procedure we do.

Try to participate in the investigation as much as possible and hopefully some good answers will be discovered, it is quite possible there was no true error but a medication reaction that caused a series of physical reactions that finally resulted in compartment syndrome. Sadly we can't always protect our patients from this kind of reaction but we can certainly begin to work on a system that decreases the risks as much as we possibly can.

You are involved in an important process and your experience and your patients experience can be a truly sad event that had an important outcome for your coworkers and for all nurses to learn from.

Great post, ITA ! :)

Try to remember that you followed established protocal, you investigated the patients complaints promptly and intervened. You were given doctors orders which you followed, you had a patent IV and gave the medication as directed. Sadly bad things can happen, every drug and every procedure we do has risks.

I know it is absolutely heartbreaking when you are trying to help someone and the treatment causes problems but it is the risk we take with every med we give and every procedure we do.

Try to participate in the investigation as much as possible and hopefully some good answers will be discovered, it is quite possible there was no true error but a medication reaction that caused a series of physical reactions that finally resulted in compartment syndrome. Sadly we can't always protect our patients from this kind of reaction but we can certainly begin to work on a system that decreases the risks as much as we possibly can.

You are involved in an important process and your experience and your patients experience can be a truly sad event that had an important outcome for your coworkers and for all nurses to learn from.

Great post, ITA ! :)

I will never, ever ever give Phenergan IV, no matter if it is ordered via central line; no matter if it is ordered by an anesthesiologist; no matter who orders it. It's my license on the line, and I know the drug, and I know my responsibility as patient advocate.

When Inapsine (Droperidol) went out of vogue for anti-nausea, there was a trend toward ordering Phernergan IV. There are people who think they can get away with it if they dilute it and give it slow IV push or IVPB, or that it's OK via PICC or IJ--BUT THE pH OF THE DRUG REMAINS THE SAME regardless of how it is diluted!!!

INS standards are very, very clear about what drugs can or cannot be given IV due to pH. Phenergan is one that is contraindicated.

I am a legal nurse consultant as well as an operating room nurse. A fellow LNC, who is an IV nurse, (CRNI) stated that she paid for the (very expensive) addition on her house by reviewing and testifying on Phenergan IV cases.

All an attorney needs to do is blow up the applicable INS standard addressing ph and display it next to the pH info about Phenergan for the jury to see. It is said that the average jury typically has an average 6th grade education and attention span, but that one is a no-brainer.

"I gave it that way because the doctor ordered it that way?" another no brainer. "Our institution commonly gives it this way?" Still another no-brainer.

Nurses have autonomy and are accountable for their own actions in a court of law. Doctor as "captain of the ship" doesn't hold up anywhere. National published standards ALWAYS override local or institutional policy and procedure. Just because your institution says it's OK does NOT make it so.

Think about what "a reasonable and prudent nurse under the same or similar circumstances" would do, and act accordingly, or even MORE reasonably and prudently, as defined by your additional experience or skill level or certification, as what I just said constitues MINIMUM standard of care.

Even a new grad who is up on her nursing school pharmacology would question whether it is "reasonable and prudent" to give Phenergan IV, as it is likely that she learned all the reasons in nursing school that it is contraindicated. Someone demands you give it that way? Show them the INS standards and refuse to do it.

There is absolutely no reason to give Phenergan IV. I have been a nurse and done multiple travel OR assignements for 23 years, and did clinical IV teaching, again in various states. Before that, I was a Navy corpsman. We have always, in my practice ANYWHERE, given it IM--or, in infants, via rectal suppository.

I will never, ever ever give Phenergan IV, no matter if it is ordered via central line; no matter if it is ordered by an anesthesiologist; no matter who orders it. It's my license on the line, and I know the drug, and I know my responsibility as patient advocate.

When Inapsine (Droperidol) went out of vogue for anti-nausea, there was a trend toward ordering Phernergan IV. There are people who think they can get away with it if they dilute it and give it slow IV push or IVPB, or that it's OK via PICC or IJ--BUT THE pH OF THE DRUG REMAINS THE SAME regardless of how it is diluted!!!

INS standards are very, very clear about what drugs can or cannot be given IV due to pH. Phenergan is one that is contraindicated.

I am a legal nurse consultant as well as an operating room nurse. A fellow LNC, who is an IV nurse, (CRNI) stated that she paid for the (very expensive) addition on her house by reviewing and testifying on Phenergan IV cases.

All an attorney needs to do is blow up the applicable INS standard addressing ph and display it next to the pH info about Phenergan for the jury to see. It is said that the average jury typically has an average 6th grade education and attention span, but that one is a no-brainer.

"I gave it that way because the doctor ordered it that way?" another no brainer. "Our institution commonly gives it this way?" Still another no-brainer.

Nurses have autonomy and are accountable for their own actions in a court of law. Doctor as "captain of the ship" doesn't hold up anywhere. National published standards ALWAYS override local or institutional policy and procedure. Just because your institution says it's OK does NOT make it so.

Think about what "a reasonable and prudent nurse under the same or similar circumstances" would do, and act accordingly, or even MORE reasonably and prudently, as defined by your additional experience or skill level or certification, as what I just said constitues MINIMUM standard of care.

Even a new grad who is up on her nursing school pharmacology would question whether it is "reasonable and prudent" to give Phenergan IV, as it is likely that she learned all the reasons in nursing school that it is contraindicated. Someone demands you give it that way? Show them the INS standards and refuse to do it.

There is absolutely no reason to give Phenergan IV. I have been a nurse and done multiple travel OR assignements for 23 years, and did clinical IV teaching, again in various states. Before that, I was a Navy corpsman. We have always, in my practice ANYWHERE, given it IM--or, in infants, via rectal suppository.

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

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

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:

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:

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