Reglan and Compazine IV push policies?

[MollyMel]

Hello,

I am a new grad, just finishing my orientation in the ED, and I have a question for the more experienced out there...

Does your hospital have a policy regarding IV push Reglan and Compazine?

My hospital states we can push Metoclopramide and Prochlorperazine, and the MDs routinely order it that way. The nurses are unanimous in their resistance to push Compazine, but are split when it comes to Reglan. All of them tell me to dilute either med in a 50ml bag of ns, but chart that I gave it IVP (that's what the MD ordered) and never tell management. The nurses are pretty hush hush about it too.

I have been researching the akathisia common with both these drugs and have found some interesting info I want to take to our ED nurse educator (I think she's kind of on everyone's team, us and management). Most of the studies are pretty old, but I guess the meds themselves have been around a while.

First, some degree of akathisia is really common with compazine administration (44% of pts according to a study in the Annals of Emergency Medicine, *1) but slowing the infusion rate is actually ineffective at preventing these symptoms (*2, *3). My Davis guide says you can administer up to 5mg/min IV, but online searches say no bolus. I'm not at work so I can't check Lexicomp. Is the best option just to make sure pts have never had a reaction before, warn them that it could happen, and give them benadryl if a reaction occurs?

On the other hand, I can't find incidence data for akathisia with Reglan, but there are a couple of studies that show that increasing the infusion time (from 2min to 15min) is very effective at reducing the feelings of restlessness etc. One study showed akathisia experienced in 11% of bolus pts vs 0% of infusion pts (*4), another 24.7% of bolus pts vs 5.8% of infusion pts. (*5)

Any thoughts?

Thanks!

*1- Drotts DL, Vinson DR. (1999) Prochlorperazine induces akathisia in emergency patients,Annals of Emergency Medicine Oct;34(4 Pt 1):469-75.

*2 Pollack, Charles. (2002) Akathisia Is No Less Likely If Prochlorperazine Is Given Slowly, Journal Watch Emergency Medicine January 2, 2002 (reviewing Collins RW et al., Ann Emerg Med 2001 Nov; 38:491-49)

*3 Vinson DR, Migala AF, Quesenberry CP Jr. (2001) Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial. Journal of Emergency Medicine. Feb;20(2):113-9

*4 Regan LA, Hoffman RS, Nelson LS. (2009) Slower infusion of metoclopramide decreases the rate of akathisia. American Journal of Emergency Medicine. 27(4):475-480.

*5 Parlak I, Atilla R, Cicek M, Parlak M, Erdur M, Guryay M, Sever M, Karaduman S. (2005). Rate of metoclopramide infusion affects the severity and incidence of akathisia, Emergency Medical Journal, 2005;22:621-624. doi: 10.1136/emj.2004.014712

[MollyMel]

Thanks!

There are a few nurses who will change the documentation to say they gave it IV in 50cc ns, but more who do not. While on orientation I have been documenting what I do (IVP or IV), and figured I could always fall back on the "I'm new" excuse if I did in fact get in trouble. Since I am going off orientation (tomorrow!) I want a clearer guidelines.

I'm not sure what the concern is, but I have definitely been told not to let the department head or NM see me put reglan or compazine in 50cc bags, and been chastised for labeling my bag with the drug and dosage (crazy, I know, and these are many of the same nurses who's precepting consisted mostly of ways to protect your license). Are 50cc bags really that expensive?

Also, I have seen nurses ask MDs switch from Reglan to Zofran if the pt has any psych history or psych med use (which would increase the risk of tardive dyskinesia or extra pyramidal SEs). I've read studies that say Zofran is more effective than reglan at relieving nausea and has fewer side effects, but I realize it is way more expensive.

I also saw many references to using benedryl with Compazine, but not reglan.

I will definitely take this to my nurse educator. Thanks!

[F.E.R.N., BSN, RN]

Interesting topic. We do not have any written policies for either drug at my facility. I worked a floor that frequently used both meds and never saw any complications, of course I suspect most of the patients there getting compazine were either (1) accustomed to it or (2) so miserable prior to it's admin that they didn't notice any side effects. I never heard a nurse on that floor mention any complications with giving either med IVP, or any special procedures r/t those drugs.

However, when I moved to the ER, I heard several nurses talk about complications such as the OP mentioned, although not the vein irritation. I have not heard any of our ER staff say they administer the meds any differently, just that they are more alert to possible side effects. I generally push both slowly, but no more than over 1-2 minutes (I might go slower with patients who lead me to think they might be more sensitive). I have had patients get restless with both meds, but never had anyoe complain about burning...maybe because most of them have had NS running and the pushes were slow (anyone in our ER getting those meds is getting at least a liter of NS, too).

Now, the only difference I see in these patient populations is that maybe those receiving the meds in the ER are unaccustomed to these meds?

I would never recommend documenting giving a med one way but doing it another.

On that note, how does everyone document when you give an IVP med that is diluted per policy? E.g., we have a policy to dilute every 25 mg of phenergan in 10cc NS for IVP...I've never known if I should document the NS. Is that CYA, or is that like documenting that you swabed the IV port or used other commonly accepted techniques?

[chelynn]

We use compazine in our ED frequently. Usual dose is 4mg IVP. I always push over 2 mins and flush afterwards if they don't have IVF but most already do. I have never seen any adverse reactions. To the previous poster, our computer charting is set up where you can chart a med then click "slow IV push over 2 mins" and "flushed with 10cc ns" If these were not available I would free text them into the chart as they are very important.

[nuangel1, BSN, RN]

we ivp both reglan and compazine .i have seen people have rxn to reglan.some people it makes hyper and very anxious.i have had people c/o feeling shaky after reglan.i have also seen a dystonic rxn to compazine in 1 girl it was awful.

[DetroitER2010]

I have never had any issues with reglan, which we give often in the ER. And in 5 years I have had one patient not be able to "sit still" and felt agitated after getting compazine which was diluted in 10cc and given over 2 mins at least. One other person had those symptoms, and that is when I had received it! it sucked, I wanted to jump out of my skin, but felt so tired at the same time! anyway,dont jeopardize your license. but dont worry that your pt will have that reaction, because ive given both drugs hundreds of times. many more issues with decadron IVP, and benadryl IVP.

[kadell]

after seeing one compazine reaction I always mix it in 50cc NS bag and let it drip slow-- I run it by the residents first but never had one object, they see it as a nrsing judgement

[snarky23]

According to Pharmacy and drug guide: Administer 1 mg compazine per minute. Dose usually calls for 10mg. I usually use a 5o ml bag and infuse over 10. When in doubt call pharmacy, or consult drug guide, use your resources people.

[snarky23]

We live in the electronic age, does your hospital not have electronic resources? When in doubt, always question what you are giving per pharmacy or drug guide, don't ask the doctors, and document that you confirmed administration. Benadryl should be given PRN not as an adjunct.Save your license.

[needsmore$]

syringe pumps are great as well-- you can set it to admin over a certain amt of time--

so-- compazine which is 1 mg/min and you want to take a few extra minutes? set it for 10 min

reglan, the same

i have seen reactions from compazine and reglan. often they are related to the rapidness of the infusion

a minute is a long time. often, when we stand there pushing meds, you may think you're taking 2-3 minutes, but in a busy ed and someone who's vomiting all over, you might be pushing it faster than you think

and how fast are flushing your int? there is med sitting in that tubing. yes, a small amt but silly to take 3 minutes to slowly push a med, then squirt in zip the flush

we give our phenergan, reglan and compazine in a 50 ml bag and run it over about 10 min. if there is a fluid restriction issue--renal patient, chf, etc, then dilute to 5-10 ml and use a syring pump.

[Maikafer-RN]

We usually give Zofran for nausea. Every once in a while we give Compazine or Reglan and I cringe when I see these orders. I've had many patient's have reactions to compazine and maybe 1 or 2 to Reglan. We don't have 50 mL handy to use - we have to get them out of the pyxis but we have 10 mL flushes to dilute.

[Lunah, MSN, RN]

And how fast are flushing your INT? There is med sitting in that tubing. Yes, a small amt but silly to take 3 minutes to slowly push a med, then squirt in ZIP the flush

LOL! Thank you, that is a pet peeve of mine.

[resus]

We give compazine a lot for migraines and it works wonders for the patients. Our docs always order Benadryl to go with it and I have never had a problem with reactions. Same goes with reglan as we are on a compazine shortage.