Problem: Promethazine (Phenergan, Wyeth) is a commonly used injectable product that possesses antihistamine, sedative, anti-motion sickness, and anti-emetic effects. The drug is also a known vesicant that 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 (IM) injection into a large muscle is the preferred parenteral route of administration, the product’s labeling states that the drug may be given by slow IV push, the method typically used in most hospitals. However, because of the frequency of serious, tragic, local injuries after infiltration or inadvertent intra-arterial injection, the Institute for Safe Medication Practices (ISMP) recommends that the FDA re-examine the product labeling and consider eliminating the intravenous (IV) route of administration. Severe tissue damage can occur regardless of the route of parenteral administration, although IV and inadvertent intra-arterial or subcutaneous (SQ) 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 a surgical intervention, such as fasciotomy, skin graft, and even amputation, has been required. The true extent of the problem may be unknown, but it appears that patients are being harmed more often than is commonly recognized. Scores of reports have been submitted to the ISMP, the U.S. Pharmacopeia, and the Pennsylvania Patient Safety Reporting System. Articles in professional literature; news of lawsuits in the media; and communications on various Internet listservs and message boards (ISMP, the National Patient Safety Foundation, http://allnurses.com, and others) have also been prevalent. The following scenarios were brought to our attention at the ISMP:
Safe Practice Recommendation: The package insert for Phenergan states: “Proper IV administration of this product is well tolerated, but use of this route is not without some hazards.” To reduce the risk of these hazards, the manufacturer recommends giving the drug in concentrations no greater than 25 mg/mL and no faster than a rate of 25 mg/minute. The drug should be injected through the tubing of an infusion set that is running and known to be functioning satisfactorily, and the injection should be stopped immediately if the patient reports burning in order to evaluate possible arterial placement or perivascular extravasation. Nonetheless, the ISMP believes that health care providers, the FDA, and promethazine manufacturers must take further action to prevent these long-standing hazards. Along with the manufacturer’s recommendations, the following strategies should be considered to prevent or minimize tissue damage when patients receive IV promethazine:
The reports described in this column were received through the ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP Web site (www.ismp.org) or communicated directly to ISMP by calling 1-800-FAILSAFE or via e-mail at gro.pmsi@ofnipmsi 1.A nurse is preparing to administer metronidazole 7.5 mg/kg via intermittent IV bolus to aclient who weighs 212lb. Available is metronidazole 500 mg/100mL. how many mLshould the nurse administer? (Round to the nearest whole number)2.A nurse is preparing to administer exenatide 10mcg subcutaneous. Available is exenatide250 mcg/mL. How many mL should the nurse administer? (Round to the nearesthundredth)3.A nurse is preparing to administer heparin 7,500 units subcutaneous. Available isheparin 10,000 units/mL. How many should the nurse administer? (Round to the nearesthundredth)4.A nurse is preparing to administer gentamicin 5 mg/kg via IV bolus to a client whoweighs 210lb. The amount available is gentamicin 10 mg/mL. How many mL should thenurse administer? (Round to the nearest whole number) |