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?
This is what I ended up having to do. The pharmacy wouldn't do it that way until I got it ordered this way. That confused me because I thought it was always given by drip, the doc wanted it by drip and said it should never be pushed, especially in an elderly person, and in a piv. When I asked another nurse she also thought it was fine to push, while most of the other staff agreed with me that dilantin has many bad SE when pushed.
Specializes in Critical Care, Emergency, Education, Informatics.
I know I'm older than dirt, but some of you may remember that we actually used to use Dilantin as an antiarythmic. It was one of the meds that we used to use in dig overdoses. You CAN give it push when using it that way, 50-100 mg q10-15 in a min. But most references including the package insert recomend a 25mg - 50mg/min dose. Rapid administration can tank your pt's BP. Our dilantin package inset states you should use a .22 micron filter. The patient should be on a cardiac monitor also.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
The next time the pharmacist questions your administration, tell him/her to do it for you. Bet he's never given it, nor seen extravasation that requires a plastics consult.
Otherwise, you're FINAL person to give it, so your safest bet is go to through the safest route.
Specializes in Emergency, Critical Care Transport.
I'm a new grad, and one of the things I remember distinctly from my ER rotation is to use a .22 micron filter with this med. I agree: be as safe as you can.
I think the rationale given to you by the pharmacist was inappropriate. I've never pushed it and if it came down to it (especially in the situation you describe), I would've done just what you did; you acted completely appropriately. Either that or hand the syringe over to the MD and let 'em have at it; only had to do this a couple of times and in both instances they suddenly became very contemplative about whether or not they *really* wanted to do what they had written in the order. Since the your patient had already had one bad incident stemming from the previous IVP Dilantin, I would consider this a prime example of a time to hold my ground. Glad they changed the order for you. I've done much more Cerebyx recently and not Dilantin, but it used to always be IVPB w/ filter.
casi, ASN, RN
2,063 Posts
Could you have gotten the ER Doc to change the order to IV Dilantin Xmg in 50ml infused over 1hr?