wrong route phenergan?

[cybernurse614]

I work at a OB/GYN clinic. I am a new RN and was asked to give phenergan IV push into already started IV. I asked the doctor if I should give the medication IM rather than IV after being warned of possible complications. The doctor wanted IV and I was advised to go slow. I diluted 25mg in 10ml 0.9% NS. The tubing used in our office requires needles for injecting into the port which I was unfamiliar with. I used a saline lock and administered over 10 min. Then restarted the IV to finish off last 500ml of LR. Patient had no complaints of pain, redness or tenderness. Now I am reading about all the complications and freaking out! Any advice would be helpful. Am I overstressing out?

[jessiern, BSN, RN]

We do give IV phen frequently, but per hospital policy we only push 12.5 mg direct IV push.

[mscsrjhm]

Just a heads up- 12.5 mg Phenergan is what damaged my daughter's veins (25 mg is her recommended dosage, but she hates the "crazy" feeling it gives her.)

[Spidey's mom, ADN, BSN, RN]

My 23 year old son experienced the extra-pyramidal side effects and won't every take phenergan again.

steph

[BluntForceTrauma]

Phenergan can be given IM or IV. Being that it is so damaging to veins, it is not recommended to give IM.

In our ICU, we frequently give Phenergan IV to the "drug seekers" who tell us IM doesn't work for them.

[GrumpyRN63, ADN, RN]

I have given it IV a gazillion times, I like to dilute it in 50cc's and run in over at least 15 minutes,( for 25 mg) have never had a problem and am quite fond over the snowing side effect... yes, your freaking out needlessly, relax...

[Fairlythere, ASN, RN]

Are you thinking of vistaril??That is no longer given IV.

[GrumpyRN63, ADN, RN]

I've never known Vistaril to be recommended IV, and it's IV compazine that causes the extrapyramidal side effects, not phenergan or vistaril

[madwife2002, BSN, RN]

My hospital and my previous hospital didn't allow usage of IV phenergan anymore. It is banned here

[espritjolieRN]

I gave IV phenergan diluted slow push a lot as well. It was in the process of being phased out when I left the floor though. Don't worry about it, you're fine.

We use needle systems in our clinic too - I prefer needleless but it's not that big of a deal. In the clinic you usually have one patient you're focusing on and one drug being given. Not like the floor where you're rushing from one patient to another and one med to another using one syringe after another. The risk is not nearly as high for us.

[NRSKarenRN, BSN, RN]

from the pharmacy experts @ institute for safe medication practices:

action needed to prevent serious tissue injury with iv promethazine

problem: promethazine (phenergan) injection is a commonly used product that possesses antihistamine, sedative, anti-motion sickness, and antiemetic effects. the drug is also a known vesicant which is highly caustic to the intima of blood vessels and surrounding tissue. formulated with phenol, promethazine has a ph between 4 and 5.5. although deep intramuscular injection into a large muscle is the preferred par-enteral route of administration, product labeling states that the drug may be given by slow iv push, which is how it is typically given in most hospitals. however, due to the frequency of severe, tragic, local injuries after infiltration or inadvertent intra-arterial injection, ismp recommends that the fda reexamine the product labeling and consider eliminating the iv route of administration.

severe tissue damage can occur regardless of the route of parenteral administration, although intravenous and inadvertent intra-arterial or subcutaneous administration results in more significant complications, including: burning, erythema, pain, swelling, severe spasm of vessels, thrombophlebitis, venous thrombosis, phlebitis, nerve damage, paralysis, abscess, tissue necrosis, and gangrene. sometimes surgical intervention has been required, including fasciotomy, skin graft, and even amputation....

...safe practice recommendations: along with the manufacturer recommendations, the following strategies should be considered to prevent or minimize tissue damage when giving iv promethazine.

limit concentration. since 25 mg/ml is the highest concentration of promethazine that can be given iv, stock only this concentration (not the 50 mg/ml concentration).

limit the dose. consider 6.25 to 12.5 mg of promethazine as the starting iv dose, especially for elderly patients. hospitals have reported that these smaller doses have proven quite effective.

dilute the drug. require further dilution of the 25 mg/ml strength to reduce vesicant effects and enable slow administration. for example, dilute the drug in 10 to 20 ml of normal saline if it will be administered via a running iv, or prepare the medication in minibags containing normal saline if there is time for pharmacy to dispense them as needed for individual patients. (trissel confirms that promethazine is physically compatible when diluted in normal saline, with little or no drug loss in 24 hours at 21 degrees c in the dark, when prepared in glass, pvc, and polyethylene-lined laminated containers [handbook on injectable drugs, 13th edition. ashp, bethesda, md; 2005:1266].) extravasation can also be recognized more quickly when promethazine is diluted than if the drug is given in a smaller volume.

use large patent veins. give the medication only through a large-bore vein (preferably via a central venous access site, but absolutely no hand or wrist veins). check patency of the access site before administration. note: according to the package insert, aspiration of dark blood does not preclude intra-arterial placement of the needle because blood can become discolored upon contact with promethazine. use of syringes with rigid plungers or small bore needles might obscure typical arterial backflow if this is relied upon alone.

inject into the furthest port. administer iv promethazine through a running iv line at the port furthest from the patient’s vein.

administer slowly. consider administering iv promethazine over 10-15 minutes. ...

[suanna]

We used to push it constantly- and it made me nuts!!!! It's very hard on the veins, it's so sedative that I often wonder if you wouldn't be safer pushing 2-4mg of versed. The "bad reactions" are rare but EVERY patient gets lethargic, somnolent, with respiratory depression-those are "normal responses" to phenergan. I have often wondered if the only reason people thought it worked is because they were so gorked they didn't now they were nauseous. Before there were other options out there it was the best way to stop uncontroled N/V, but Zofran and Kytril have been around for long enough to have a proven track record. My hospital used to insist on phenergan as the drug of choice without a specific order of why it wasn't used instead of zofran/kytril. They admitted it was a $ issue. The docs threw enough fits that we are at least seeing a 50/50split. Hopefully, in the future, phenergan will be a intervention of last resort.

[burnoutward, BSN, RN]

We can only give 12.5mg IV per pharmacy protocol at my hospital. It is a pain the ass, I'd rather just pull up and give IM personally, seems to be more effective and stays with patient longer.