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. AmericanJournal 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
I push Reglan and hang Compazine in a 50cc bag of ns. I push every med slow slow, over 2 minutes. Unless it's a code situation or adenosine. I have never had an incident of reaction of restlessness or anxiety attach with either drug.
Phenergan is another one you must give slow because of irritation to tissue. I hate giving it. Zofran, in my experience, works the best, but when that's proven ineffective for some, mostly people who are sick, i.e. cancer, sickle cell pt's, reglan or compazine seem to be the drug of choice. I always ask the sick pt because they know what works for them and what their allergy or reactions are.
I had something quite different happen to me today after pushing Compazine 10mg. I've given this 100's of times. Gave the med diluted in 10ml NS very slow (over 5 minutes). He started feeling funny and agitated so I went to grab some Benadryl and get the doctor. Walked back into the room and he was having a tonic like seizure. Eyes rolled back, clenched hands, jaw locked and was incontinent of urine. It lasted about 90 seconds. He came to and was very withdrawn but was able to answer questions normally after about 5 minutes. I've seen Compazine reactions before, but never one this severe. This was a first for me after giving the med for over 10 years. Pretty crazy!
Specializes in Emergency, Critical Care (CEN, CCRN).
We don't do a whole lot with Reglan; our go-to medication for nausea is Zofran, followed by Phenergan if that doesn't work. Migraineurs usually get the Benadryl/Compazine/Toradol cocktail, along with a liter 0.9% bolus. Rarely we'll do Compazine or even Thorazine drips for refractory migraine or oncology patients who come in with intractable nausea and vomiting.
In any case, I always dilute my phenothiazines in a 10 mL flush syringe, time myself over three minutes, and I'd rather give them in a running line of 0.9% if I have one up. (In the EC, just about everyone does.) Hospital policy only singles out Phenergan; when given IVP, it must be given in a running line through a central or large-bore peripheral access (20 ga or bigger) over 3-5 min, and you must instruct the patient to tell you about any burning, irritation or redness at the site. Using that method, I haven't had a problem with any of them yet. I like the idea about using a syringe pump, though - we usually keep those over on the peds side, I hadn't thought of using one on adults. I'll have to try that sometime...
As for the bit about using 50 mL piggybacks for "slow push" meds, we leave that up to nursing judgment. There's a Pyxis override category for "sodium chloride 0.9% for flush/diluent/KVO", so you can always pull a mini-bag and load it with your med of choice. You then chart the mini off under standing orders, with a note to the effect of "0.9% diluent for IV (med) administration."
roses1130j
20 Posts
I push Reglan and hang Compazine in a 50cc bag of ns. I push every med slow slow, over 2 minutes. Unless it's a code situation or adenosine. I have never had an incident of reaction of restlessness or anxiety attach with either drug.
Phenergan is another one you must give slow because of irritation to tissue. I hate giving it. Zofran, in my experience, works the best, but when that's proven ineffective for some, mostly people who are sick, i.e. cancer, sickle cell pt's, reglan or compazine seem to be the drug of choice. I always ask the sick pt because they know what works for them and what their allergy or reactions are.