compartment syndrome-did I cause it? - page 4

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... Read More

  1. by   P_RN
    Inadvertent Intra-Arterial Injection: Due to the close proximity of arteries and veins in the areas most commonly used for intravenous injection, extreme care should be exercised to avoid perivascular extravasation or inadvertent intra-arterial injection. Reports compatible with inadvertent intra-arterial injection of promethazine, usually in conjunction with other drugs intended for intravenous use, suggest that pain, severe chemical irritation, severe spasm of distal vessels, and resultant gangrene requiring amputation are likely under such circumstances. Intravenous injection was intended in all cases reported, but perivascular extravasation or arterial placement of the needle is now suspect. There is no proven successful management of this condition after it occurs, although sympathetic block and heparinization are commonly employed during the acute management because of the results of animal experiments with other known arteriolar irritants. Aspiration of dark blood does not preclude intra-arterial needle placement, because blood is discolored upon contact with promethazine. Use of syringes with rigid plungers or of small bore needles might obscure typical arterial backflow if this is relied upon alone.

    When used intravenously, promethazine hydrochloride should be given in a concentration no greater than 25 mg per ml and at a rate not to exceed 25 mg per minute. When administering any irritant drug intravenously, it is usually preferable to inject it through the tubing of an intravenous infusion set that is known to be functioning satisfactorily. In the event that a patient complains of pain during intended intravenous injection of promethazine, the injection should immediately be stopped to provide for evaluation of possible arterial placement or perivascular extravasation.
    Demerol can also burn like hades when given IV. The 50mg glass amps of phenergan are marked in tall letters NOT FOR IV USE.

    I wonder if being a smaller (20) int it was beginning to infiltrate as mentioned above. The sentinel event investigation looks to be fairly standard. Did you feel that there were accusatory statements? It seems to me you did everything properly. Let us know if you get an outcome report.
  2. by   stevierae
    Quote from 3rdShiftGuy
    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.
    3rd shift guy, you won't have to take them down with you--believe me, they will all go down, because of the deep pockets theory, and the fact that the hospital is held liable for the actions of its employees. The plaintiff attorneys will be right on top of taking everybody down.

    The other thing about extravasations, especially of vesicants--one is expected to treat the extravasation RIGHT AWAY with the agent that can neutralize it, and in most cases that agent is Wydase. Now, I know that for a long time Wydase was unavailable; I don't know if there was a shortage of it nationwide or if the manufactureers quit making it.

    So, what do you do if you do not have the proper antidote to treat an extravasation? You DON'T GIVE THE MEDICATION IV!!!

    If the pharmacy/nursing committees disagree with you and give you all kinds of half-a**ed rationales why your hospital has found the practice of giving Phenergan through a peripheral IV acceptable, simply show them the published INS standards. They cannot argue with those in a court of law.
  3. by   teeituptom
    Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis
  4. by   stevierae
    Quote from teeituptom
    Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis
    The only problems you have encountered TO DATE have been pain and superficial thrombophlebitis. You have been exceptionally lucky.

    I repeat: The fact that you give it "all the time" in your institution will not make a difference in a court of law when a more serious IV Phenergan complication occurs in your institution--and the INS standards are blown up to about 100 times their textbook size, and set side by side with the package insert stating the pH of Phenergan, also blown up, for a jury to view.

    Juries don't like nurses who choose to ignore evidence-based standards in favor of what "they do all the time" or "what their institution does all the time."

    All a savvy plaintiff attorney has to ask the nurse on the witness stand who gave it, "Would you have felt comfortable ignoring the published INS standards and giving Phenergan through a peripheral IV if the patient were YOUR MOTHER?" (or wife, or sister, etc.) and then looking in disgust at the jury while that nurse hemmed and hawed through his/her answer.

    Another no-brainer.
    Last edit by stevierae on Apr 25, '04
  5. by   teeituptom
    Phenergan has been given IV,IM,PO,and PR for a long time now. Its accepted practice. I personally prefer Zofran as its more effective. But I have patients who much prefer Promethazine.We use it all the time, with only rare problems mostly associated with Dystonic reactions.

    And yes I have given it to my wife, she didnt like the "Burn" but that only lasts a few minutes,

    and as far as lawyers go
    deep down they are basically good
    six feet down that is
  6. by   Repat
    We give Phenergan all the time IV, and I have never noticed a problem. Occasionally a patient will complain that it burns, but that it about it. As Tom says, I have noted a few (a very few) dystonic reactions, and occasionally it really "snows" a patient, but I admit I have never heard this controversy before (and I have worked in many states and settings).
  7. by   Tweety
    [QUOTE=stevierae]So, what do you do if you do not have the proper antidote to treat an extravasation? You DON'T GIVE THE MEDICATION IV!!!QUOTE]

    Yep. No brainer there. Thanks.
  8. by   teeituptom
    so what hospital wouldnt carry antidotes for extravasation
  9. by   Tweety
    Quote from teeituptom
    so what hospital wouldnt carry antidotes for extravasation
    Those that have lost the lawsuits that stevierae is talking about.
  10. by   stevierae
    Quote from teeituptom
    Phenergan has been given IV for a long time now. Its accepted practice. :

    Sigh. There is just no reasoning with you, Tom, so I will not try. I have seen some of your other posts regarding giving IV Propofol to non-intubated patients in the ER setting--a very, very dangerous practice, and one that has resulted in many unnecessary, tragic deaths nationwide. But, you cited the same rationale you did with Phenergan via peripheral IV: "We do it all the time. No biggie."

    Phenergan via peripheral IV is NOT accepted practice.

    Those institutions, and those nurses, who choose to ignore published, evidence based practice standards and do so does not MAKE it accepted practice.

    Those nurses who choose to ignore published evidence based practice standards are at risk of sitting in a courtroom, because there will be a legal nurse consultant just like me behind the scenes showing the plaintiff attorney the evidence based practice standards. As I said, those ALWAYS overrule regional or institutional policy and procedure. To the fact finders,(judge and jury) they are all that matter. Anecdotal testimony from a nurse who "does it all the time; no biggie" will simply increase the amount of the award to the plaintiff.

    As I said, juries do not like arrogant nurses who choose to ignore published evidence based practices.

    Interestingly, the peripheral IV Phenergan extravasation case I am currently reviewing is a Texas one--from a small town near Austin. Happened in the ER. If this case costs this hospital big money, (and it will) you can bet that, in Texas, your practice of giving IV Phenergan "all the time" despite what published evidence based practices state will cease, once and for all.

    Why take the risk, when it could possibly cost the patient a limb? Why risk your own license and professional reputation? Give it IM or, if a peds patient, via rectal suppository.
  11. by   mattsmom81
    What about the percentages of people who have recieved Phenergan WITHOUT problem over the decades?? Every drug has untoward effects listed in the PDR...and a small percentage of patients will react badly. Those numbers are small or the FDA would NOT release them.

    Hopefully people (juries) are smart enough to understand that a few bad outcomes will always be found...also that there will always be a lawyer (and their 'expert witnesses') close by to point a finger. Life is certainly not risk free: not for patients nor nurses.

    Texas leads the nation in lawsuits against nurses...the attorneys and their 'expert witnesses' seem to be doing well here, unfortunately. I've given Phenergan for 28 yrs without major problems but all of a sudden its a lawsuit inducing drug? Hmmm...whatever. I'll make sure to have a good attorney in MY corner too if I get taken to court about Phenergan.

    Since we're in Texas and I better be careful.
  12. by   teeituptom
    I like attacks

    1. as long as the PDR says it can be given IV

    2. as long as my hospitals formulary says it can be given IV

    3. as long as the doctor orders it IV

    4. as long as the patient has no allergy to phenergan

    Then, no, I dont have a leg to stand on to refuse an order.
    If you want, change the system and I will change also.
    But I cant tell a doctor or my supervisor that I refuse to give phenergan IV because I read it on All Nurses .com message board. Somehow or another I dont think that will fly in the face as numbers 1 , 2 , 3.

    Now we know attorneys are really nice people,
    however if paid they will sue anyone with whatever complaint they can come up with. Weve all seen that before and they even advertise that on TV. " hello; Im so and so" did you have a fender bender let me get the big bucks for you.
  13. by   teeituptom
    and particularly since there are more shysters in Texas than anywhere else in the country