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Discussion

What do you guys think of this?

So we were REALLY full last night and had to hold some of the sicker patients for a long time because floors were full. When I came on I got a 86 y/o man who was a SAH and very confused normally (brain tumor), they had already lost several IV on his very frail veins and I had just removed one because someone had given dilantin to him IVP which had extravastated and cause massive (I mean massive) edema and purple-black discoloration to his hand and halfway up his arm. I nursed it all night, and it had gotten a little better, but by this point I had started two more IVs in his other hand due to him pulling them out and he had no more places to put an IV, and was not a candidate for a central line or even a PICC.

So 8 hours later when it was time to give him another dose of dilantin, I called the pharmacy and asked them to send it in a drip, and they told me no because it was wasteful, and that there was no reason why I couldn't give it by IVP and that the ICU always does it that way, so why did I have a problem with it. I talked to another nurse about it and she said that giving dilantin IVP is always acceptable, however everyone else agreed with me that it should never be given IVP unless absolutely necessary, especially through a peripheral due to potential purple hand syndrome, and potential necrosis. I learned this a long time ago, and am wondering if something has changed.

I also feel that I should not have been questioned like I was regarding this since I had my reasoning and it wasn't related to wasting resources (poor access, elderly, multiple problems, etc). I guess I just don't see what the big deal was. They only would send it to me in a bag after I got the MD to order that it be given per drip. The original order didn't specify by push or drip, just said "dilantin 100mg intravenously"

So I guess I'm asking if everyone routinely given dilantin by IVP or by drip, what are your policies regarding it's IV administration?

Thanks so much!

Featured Replies

We don't give it IVP. Dilantin hurts like a you know what. That's why the infusion can't run longer than an hour or the tubing set will start to breakdown. I like to run it into a 20g in a larger vein if possible.

  • Author

Thanks PAERRN20, your right I didn't mention "the burn", but that was also another reason I didn't want to push it. I feel like if you are required to use a filter on it, and change the tubing every time you use it, it can't be good for a very small, frail, vein.

I just feel like I missed something? Every other time I have gotten dilantin from the pharmacy, it was in a 50mL bag, and we actually have to call them (even though we have Echarting and they see the order right away) when we need it because it is only stable for 4 hours.

Why a filter?...am I missing something here? You mean a blood product filter or a filter d/t it being stored in a glass vial? Small doses I've always just diluted it and given it as a slow IVP (and used a filter needle to draw it out of the glass vial)...never had a problem.

I have always given it as a drip with a filter. In fact, I had to give it recently and the pharmacist brought the IV bag to the floor and handed it to me in person so that he could tell me to make sure to put a filter on it. He even told me that although we do not have a policy stating that I couldn't push it, he would strongly discourage it.

i think the big question is, why are you using phenytoin instead of fosphenytoin?

  • Author

Our policy (when its in a drip) is to use a 0.22 filter on the tubing, there is even a warning set up on our pumps (lots of problems with precipitate)

And morte, you know that we have to give phenytoin if that what was ordered, not my favorite drug either, but education only goes so far with some folks:)

Just trying to see if I was the only one who learned that it is BAD to give IVP-thanks everyone!

Our policy (when its in a drip) is to use a 0.22 filter on the tubing, there is even a warning set up on our pumps (lots of problems with precipitate)

And morte, you know that we have to give phenytoin if that what was ordered, not my favorite drug either, but education only goes so far with some folks:)

Just trying to see if I was the only one who learned that it is BAD to give IVP-thanks everyone!

the you was meant in the plural/collective, not singular......working in ltc, i dont see this any more, when i did, IVP was the usual, do to instability....and the drug books read that it should not be done without cardiac monitors....

I asked my pharmacist friend about this because I have never used a filter and she said that the formulation we have does not require a filter...hmmm

????Look up Dilantin and you will find (possible) side effect is "V FIB"!!!! Why would anyone push that??? Also literature is pretty clear about using a large vein... What kind of pharmacist would think it wasteful to dilute it? I have had somewhat similar experiences i.e. pt could not tolerate and I reported it to E.R. MD who then changed order to phosphenytoin.

I would have made up a drip myself.

  • Author

I would have made up a drip myself, but the point was that I called them ahead of time so as to be sure that THEY would send a drip every time, I didn't want anyone who didn't know better to push it on this poor man.

Could you have gotten the ER Doc to change the order to IV Dilantin Xmg in 50ml infused over 1hr?

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