purple glove syndrome

[underdogRN]

Hello everyone. I am a neurosciences RN and I am working on the problem of purple glove syndrome-the infiltration of IV dilantin. We are trying to develop a protocol for site monitoring after a possible infiltrate of this drug. What is the best tx? At what point should the service be notified? I'm also interested in policies for administration of IV dilantin. Should it be diluted? What is an acceptable ammount to give IV push-100mg? 300mg? Thank you :)

[caroladybelle, BSN, RN]

The big question is why are facilities giving IV Dilantin at all.

Cerebyx (fosphenytoin) is much safer IV, can be given more rapidly in an emergency, is less likely to precipitate/more compatible with several IV fluids, and not likely to cause nearly as much damage to tissue if it infiltrates.

[underdogRN]

Our sources say that fosphenytion also can precipitate and cause simmilar tissue damage. It is also much more expencive than dilantin, however we do use it for emergency doses.

[caroladybelle, BSN, RN]

There are substantially less problems with it than phenytoin. The vast majority of facilities I have worked have switched to it despite the cost....they figure that it is cheaper than a few lawsuits that using phenytoin peripherally would get them.

[lsyorke, RN]

We no longer use dilantin IV at all.

[P_RN, ADN, RN]

I haven't used dilantin in nearly a decade. Is this a US hospital?

[nuangel1, BSN, RN]

i hav eheard of the cerebyx .but most of the hopsitals i worked at in the last 10 yrs still use dilantin.

[LilRedRN1973]

We still use Dilantin IV. I HATE giving it IV, especially if there is no central line available. In my first month of being a tech on this unit (ICU), I witnessed a horrendous Dilantin infiltration and the woman ended up losing her hand. It was horrible and to this day, I flashback to that poor woman's hand when I have to given Dilantin IV. Sigh.

Melanie

[RoxanRN]

If we only have a peripheral site, we use Cerebyx. We try to restrict dilantin to central lines. If it has to be given peripherally, we have to do an 'Irrititant Flowsheet' - site checks every 15 minutes (or more frequently) during infusion. We also never 'push' more than 100mg (I put it on piggyback in the pump at 100+ml/hr). Anything higher is mixed by pharmacy and given over 1 hour.

[pjdxxxwa]

As with any IV drug that can potentially harm a patient there are things to do. Dilute with a sterile 0.9% saline solution AND inject slowly into the vein. Some drugs need to be injected over 5 or 10 minutes time. THIS time frame is often overlooked and the most important aspect of preventing harm to a patient.

IMHO all hospital Pharmacists need to put specific administration directions on drugs they send and all administering personnel needs to also do research on how to give potentially dangerous drugs. Inservices, ask Administrators to phone the drug company (or do so yourself), and so forth. :typing

This forum is a good start for getting answers but we also need to take the initiative for researching certain things ourselves, also. :)

[GingerSue]

This is from Abrams Clinical Drug Therapy:

"phenytoin solution is highly alkaline and physically incompatible with other drugs. A precipitate forms if mixing is attempted... Give phenytoin as an undiluted intravenous bolus injection at a rate not exceeding 50 mg/min, then flush the IV line with normal saline or dilute in 50 - 100 mL of normal saline (0.9% NaCl) and administer over approximately 30 - 60 minutes. If piggybacked into a primary IV line, the primary IV solution must be normal saline or the line must be flushed with normal saline before and after administration of phenytoin. An in-line filter is recommended....Phenytoin cannot be diluted or given in IV fluids other than normal saline because it precipitates within minutes. Slow administration and dilution decrease local venous irritation from the highly alkaline drug solution. Rapid administration must be avoided because it may produce myocardial depression, hypotension, cardiac dysrhythmias, and even cardiac arrest."

[pjdxxxwa]

Ginger, thanks for adding the flush after the slow injection (which I omitted) and reaffirming that SLOW ADMINISTRATION and NS should the be the only dilution.