Read case reports of what promethazine can do to subcutaneous tissue here. http://www.ismp.org/Newsletters/nursing/Issues/NurseAdviseERR200608.pdf
A completely patent I.V. site is a mandate for promethazine. The most important things to assess include:
- The age of the I.V. catheter – if it has been indwelling for more than 24 hours it has a much higher risk of extravasation. But don’t assume that a newly inserted catheter is completely patent.
- The location of the I.V. catheter – veins of the hand, wrist, and antecubital fossa should NEVER be used for promethazine. There is a greater risk of nerve injury in these locations. Nerve injury from direct venipuncture and compression from fluid in the tissue can produce complex regional pain syndrome (CRPS), a lifelong chronic severe nerve pain condition.
- Site condition – look for any redness, edema, or other changes. Always aspirate for a blood return that is the color and consistency of whole blood – pink-tinged fluid is not enough!
- Patient complaints – this is always a valid reason to not use this site for promethazine. Pay careful attention to what the patient is telling you and never try to explain away those complaints. Always change to another I.V. site even it is means inserting a new catheter.
Think carefully about how you and your colleagues give this drug by the I.V. route. ISMP recommends dilution, yet the manufacturer’s instructions state it can be given undiluted. I strongly recommend dilution in a 10 mL syringe and pushing slowly while aspirating for a blood return every 2-3 mLs. Dilution in a minibag and giving by piggyback is not a good practice, in my opinion, because the nurse will leave while this is infusing and there is no constant monitoring of the site and frequent checks for blood return. In addition, there must be fluids infusing through the site while you are injecting promethazine to provide additional fluids to flush the vein. A small gauge catheter in the largest vein possible will increase the blood flow around the catheter but infusing fluids also are recommended.
Once promethazine has entered the tissue, there are very few, if any, effective treatments. Therefore, prevention of extravasation is crucial. So, take plenty of time to assess this I.V. catheter and vein for complete patency.
As will all drugs, the person giving the medication is responsible for doing the procedure, but we are also held accountable for the outcome of our actions. If there is no prescription for infusing fluids, ask for the order. Suggest other medications instead of promethazine. Alternatively, suggest another route of administration if promethazine is the best drug for your patient.
Lawsuits with this drug continue including outcomes of CRPS, necrotic ulcer with or without surgical debridement, and amputation. Most lawsuits will end in a settlement out of court, which always means a private agreement. This is the reason that the number of actual cases and the dollar amount of the settlements are unknown.
A nurse with knowledge about the risk with promethazine, and the correct administration methods, along with the skills for an in-depth I.V. site assessment can prevent these problems, protect your patient from the devastating injuries, and protect yourself and facility from a lawsuit.
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