I am closing yet another case involving extravasation of promethazine. When will these cases end? Although the Institute for Safe Medication Practices (ISMP) issued warnings and recommendations about I.V. promethazine in 2006, many hospitals have not addressed this issue. The ISMP includes promethazine on their List of High-Alert Medications in Acute Care Settings. Click here to download this list http://www.ismp.org/tools/highalertmedications.pdf
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:
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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Author: Lynn Hadaway
Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.