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 :)

[nrsang97, BSN, RN]

I have never seen fosphenotyin (sp?). We still give dilantin. We do give peripheral, and at the first time a patient says that it hurts we stop it and change IV sites. If able we just give it PO.

[NurseyPoo7]

Ive never seen fosphenotyin , either. We give IV dilantin still. I work on a "neuro" unit. We get CVAs and seizures, but we just moved over and havent started getting brain injuries, spinal cord injuries yet.

My hospital is considered the most advanced/"best" hospital in a 2.5 hour drive radius.

[iluvivt, BSN, RN]

Before you look at the site monitoring post incident you really need to look at the main issue of prevention. Extravasation and PGS can be greatly reduced with prevention strategies and nurse education. Have specific guidelines for the site assessment,administration as well as helping nurses identify those at risk so they can increase monitoring. As an IV specialist I have seen many unfortunate outcomes that could have been prevented with better nursing care. Here are the items I would include in a policy or teach.

1. Perform a complete site assessment before administation. If the site is old do not use it. The older the site the greater the chance of complications. Do not administer the dose if IV site is at an area of flexion or worse yet in the hand. About 50 % of PIV complications occur at an area of flexion. Leakage of irritating drugs into the hand can cause severe damage in this area to the lack of tissue and can cause functional losses.

As always it is best to place the smallest shortest cannula that will meet your needs and in this case use a large soft vein in an area with some tissue.

2. Administer per protocol with NS flush...then push dose at a minimum of 50 mg a min....followed by another slow NS flush. I think at least 10 ml of NS should be used for both flushes. Stay with the patient and do not use a syringe pump and monitor the site. If the patient complains of pain or burning stop the infusion and re-assess....line probably needs to be discontinued. try to limit your push doses.

3. Larger doses need to be administered via partial fill or mini-bag and a .22 micron filter needs to be added as close to the site as possible as possible. The site will also need to be checked at least every 15 min.

4 If the nurse thinks that a patient does not have suitable veins to sustain the prescribed therapy...I would call the MD and request a CVC or the Fosphenytoin.

POST Extravasation or PGs

1. Discontinue the site.

2. Notify MD after assessment

3. Elevate affected limb and apply cool compress.(A few sources will say warm but the consensus among experts is cool). Cool compress 20-30 min at least qid.

4. Mark the site of discoloration to track progression or resolution.Assess for coolness pain and edema and discoloration as these are hallmarks of the syndrome. Also monitor for compartment syndrome and check distal pulses. Any evidence of Compartment syndrome and MD needs another call STAT as this is a medical emergency. Medicate pt prn for the pain and discomfort. Re-site IV prn in opposite extremity.

5. On-going assessment needed as these injuries can sometimes take weeks for the necrosis to appear. Upon discharge there should be documentation that the pt or caregiver has been instructed to seek medical care should any symptoms occur.

6. PS There has been 1 or 2 case reports of the use of Hyaluronidase to treat this

I hope I got everything If I think of anything else I will add it later Mary