Phenergan IV changes in policy

[RNKPCE]

Have your hospitals recently changed their policy for IV Phenergan? Just this week I noticed that we now have to try 6.25mg first then 12.5mg, it has to be diluted in 20ml and given over 15 minutes. Now I know why I got in report from the ER that they gave a patient Zofran for nausea. They never use to give Zofran. I looked up some stuff on the internet and I guess Phenergan is a vesicant that can cause loss of limb if injected interarterial. What are the other reasons for the change? If this is true I can see why the policy change, but I am sure a vomiting patient will not like waiting 15 minutes for the Phenergan to be injected.

[jannrn]

I use the pre-filled syringes. I draw up the needed amt of med with the blunt tip (metal, not plastic) type needle and squirt it in the 10 cc syringe with saline in it. sometimes I have to squirt some saline out first to make the med fit. I only do one med at a time to know which med is in the syringe, if I have alot, I'll take the supplies in the room and do them one at a time. the flush syringe I leave in the sealed package to know that it is the flush with no med.

I was have been told the 20ml vials of saline have preservative in them and it is not good to give large amounts. I'd have to check the label, but that is what I was told. the pre-filled syringes I was told do not have the preservative, so it is better if you are pushing the whole amount or several at a time to use those. However, I have also wondered if administration would prefer me to draw up my own as it would be cheaper.

[GardenDove]

Yep! I do the same thing - our floor carries stock of 10cc flushes (for flushing PICCs) - if I'm doubtful, I use a 15 cc syringe and draw up more saline.

Except that right after I draw it, I wrap a piece of tape around the syringe and write down what's in the syringe (e.g. Phenergan 25mg)... habit I picked up when I was precepting in the ER.

I know! I know! Not exactly the safest thing to do - but I believe it's better than an unlabeled, 'who knows what is in this thing and why is it infusing through that there' approach

Once that's done, snap it into the mini-infuser and let it run through a running IV.

I don't see what's unsafe about it, as long as you label it. We don't have syringe infusers where I work, but I'll attach it to the secondery port and program in 10 cc's volume to go in at 40-60 cc's an hour, and that works fine. Then the empty syringe is there to be used in case the primary line goes dry and needs to be back primed.

[all4schwa]

we spike a liter bag with a luer lock and draw saline that way, i automatically grab a 12ml and dilute everything.

we mostly use anzemet, does it cause the same problems?

and, if phenergan is so irritating to the veins, why can it be given IM?

[JessicRN]

We have not changed any of our policies regarding phenergan it is given 25mg IVP there is no amount how to dilute it. I questioned it and even refused to give it as the pt is a drug addict and the only IV he had was in his thumb. The supervisor came down and told me to give it as there is no change here. I did luckily convince the doctor to decrease it to 6.5 but I was told if I refused again I would be written up

[CritterLover, BSN, RN]

we spike a liter bag with a luer lock and draw saline that way, i automatically grab a 12ml and dilute everything.

we mostly use anzemet, does it cause the same problems?

and, if phenergan is so irritating to the veins, why can it be given im?

no, anzemet/zofran do not cause the same problems. they are not considered to be vesicants or irritants.

im is a better route for most (not all) irritating meds. why? because the big muscle can tolerate it. it may burn, but you arn't damaging the muscle tissue. think about all of the burning, irritating antibiotics that are given im. plus all of the meds that are given safely im, but have to be given via the z-track method, so that the subq tissues arn't harmed.

some meds can't be given im -- due to kinetic factors; or other factors, like heparin -- giving heparin im would cause local bleeding/hematoma.

[General E. Speaking, RN, RN]

I wish we gave more Zofran. Phenergan is irritating. We have guidelines about diluting with NS that print up on our MARs. However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning. They change it in the doctor's order and write per Executive Medical Committee (or something). Pharmacy also changes every Demerol order to an equivalent Morphine dose (unless they are allergic). The only way around it is if the doc writes "do not substitute". Yep, it ticks the docs off, but most of them are used to it now. Some of our surgeons will only order Phenergan IM.

[GardenDove]

Hi, I'm at work, and my little email did the trick. My manager forwarded it to pharmacy and there was reminder spiel on an IV phenergan order I have tonight saying " To prevent rare instance of tissue necrosis: Dilute in 5-10 ml of saline: inject into a running IV (if possible) using the port ruthest from the patient's vein. (Max IV push dose 25 mg)"

[nursemike, ASN, RN]

Hi, I'm at work, and my little email did the trick. My manager forwarded it to pharmacy and there was reminder spiel on an IV phenergan order I have tonight saying " To prevent rare instance of tissue necrosis: Dilute in 5-10 ml of saline: inject into a running IV (if possible) using the port ruthest from the patient's vein. (Max IV push dose 25 mg)"

That is so cool--to see results that soon! Good for you and your manager.

We've had a lot of education on phenergan, lately, too. We do give it IV, and I've never had a pt complain of it burning--I dilute it and push it slow. Real slow. But reading this thread, I'm thinking it'd be better to set up a bag of NS--even a 100ml bag--to run it with.

A little off-topic, perhaps, we've had a lot of concern over IV dilantin. Last year we had what I assume was reported as a sentinal event--patient supposedly lost hand over IV dilantin. I can't verify that, but I did see the necrotic hand. Very sad, and scary, because we push dilantin a lot.

I felt bad when I learned that a lot of more experienced nurses were routinely diluting dilantin. All I'd ever seen was push it very slowly in a good site and flush thoroughly, so that's how I did it. Since this incident, we've had inservices and been taught do not dilute dilantin. But the rational was that diluting it didn't change the pH--which, I think, is clearly wrong. If you dilute HCl, you change it's pH. And it's supposedly okay to give through a running IV, if compatible, which seems like dilution, to me. Anyway, I was glad I'd been doing it right, after all, and I've never had a pt complain of burning with it, either.

So, does anyone happen to know why we shouldn't dilute dilantin? My best guess was maybe a risk of precipitation, but my drug guide doesn't say.

[Roy Fokker, BSN, RN]

I wish we gave more Zofran. Phenergan is irritating.

I agree...

... but for some of my post op patients - Droperidol doesn't work. Granisetron doesn't work. Ondansetron doesn't work.

But Phenergan does.

However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning. They change it in the doctor's order and write per Executive Medical Committee (or something). The only way around it is if the doc writes "do not substitute". Yep, it ticks the docs off, but most of them are used to it now. Some of our surgeons will only order Phenergan IM.

Our pharmacy auto-subs Kytril (Granisetron) for Zofran.

I personally like Droperidol - though the way we stock it on the floors is pretty stupid (usual dosage is 0.625mg - 1.25 mg... but out ampules on the floor are 2.5mg/2ml! It's kinda wasteful drawing up 0.25 mls per ampule and throwing the rest away! )

[meandragonbrett]

However, our pharmacy changes all our doctors Q4-6 hr Zofran orders to Q DAY!!! Something about it being expensive and is really for cancer patients...I can't remember their reasoning.

Why is the hospital worried about it being expensive? This is insane. I was recently in the hospital and I was getting Zofran and Phenergan like crazy. I'd have been highly upset if the pharmacy told me I could have only had the zofran QDay. Who cares if it was intended for cancer patients if it works for other patients. Geez. The only thing our pharmacy changes is any orders written for Prevacid get changed to Protonix IV.

[Dooney121]

I have seen Pt's have to get amputated hands due to giving IV Phenergan have to make sure IV site is good.

[CritterLover, BSN, RN]

i hadn't heard about not using prefilled syringes to dilute. do you have a rationale for that? i've been using them lately because it's faster than drawing up saline. i'll eject unneeded saline and carefully draw up the correct amount of med, such as ativan. i've found that convenient and thought it would be more sterile. i'll just add a needle to draw up the med.

if you want to add something to a bag of saline, there is a port where you can do that, you just draw up the med and inject the proper dosage into the saline bag, usually a 50 or 100 cc bag. then put on a medication added label.

i do the same thing.

however, the ismp newsletter this month had a big article in it talking about why this shouldn't be done.

their argument is that since the pre-filled syringes are labeled with the drug/concentration, once you add a med to it, the label is no longer correct. even if you add a label to the syringe, it could fall off, i guess.

i have all of the ismp newsletters emailed to me at work, and have often thought that they are a little "over the top" with some of their safety concerns. at times it seems as though they don't give nurses any credit for having any brainpower whatsoever.

but then of course a patient died from an 8 gram loading dose of dilantin, and now i wonder if some nurses do have any brainpower at all. :uhoh21:

ismp link: http://www.ismp.org/nursingarticles/list.htm