I don’t usually respond on here so I
may not be doing this correctly. We had a pt who had to have dilantin IV
for months along with TPN infusion. We had difficulty with
precipitation. What worked was a dual lumen PICC with one side for TPN
and the other for Dilantin and NS only. We gave fosphenytoin which is a
more soluble form of IV dilantin.
Debbie Smothers
Vascular Access Case Manager
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-----Original Message-----
From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Stranz, Marc
Sent: Tuesday, February 14, 2006
5:39 PM
To: 'Lynn Hadaway';
Kokotis, Kathy; [EMAIL PROTECTED]; Heather Nichols; [EMAIL PROTECTED];
Leigh Ann Bowe-geddes; [EMAIL PROTECTED]
Subject: RE: [vascular] RE:
Dilantin
You could create a situation that would destabilize
Dilantin enough to crystallize the product. The variables around that
situation are significant, but the extreme is precipitation and redissolution
from the injection site comparable to IM injection. Not a pleasant thing
to have happen, so clearly site selection is critical to successful administration
- with success measured as response and consequences.
Kostenbauder HB, Rapp RP, McGovren JP, Foster TS,
Perrier DG, Blacker HM, Hulon WC, Kinkel AW. Bioavailability and single-dose
pharmacokinetics of intramuscular phenytoin. Clin Pharmacol Ther. 1975
Oct;18(4):449-56.
Comparison of phenytoin plasma concentrations in an
intravenous and intramuscular crossover study in 12 healthy ambulant, male
subjects indicates that phenytoin administered intramuscularly is absorbed over
a period of approximately five days. A model simulating precipitation and
redissolution of the drug at the injection site has been shown to
satisfactorily fit observed plasma concentration data following intramuscular
administration. It is proposed that this model will be useful in the selection
of an appropriate dosing regimen in situations in which intramuscular
administration of phenytoin is indicated.
marc
-----Original Message-----
From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]On
Behalf Of Lynn Hadaway
Sent: Tuesday, February 14, 2006
8:19 AM
To: Kokotis, Kathy;
[EMAIL PROTECTED]; Heather Nichols; [EMAIL PROTECTED]; Leigh Ann
Bowe-geddes; [EMAIL PROTECTED]
Subject: RE: [vascular] RE: Dilantin
No evidence either way according to Marc's response.
Lynn
At 7:54 PM -0700 2/13/06, Kokotis, Kathy wrote:
>So it sounds like in a
peripheral vein dilantin and blood could
>precipitate together as the
flow is slow and the volume low. I have
>seen hardened veins from
dilantin as an ICU nurse in the peripheral
>system. Whether that is
from residual fluid in the tubing or slow
>flow who knows. Unless we
do autopsy I don't think we would ever
>know. Sounds to me that
you need a large flow to prevent the
>precipitation
>kathy
>
>________________________________
>
>From:
[EMAIL PROTECTED] on behalf of Lynn Hadaway
>Sent: Mon 2/13/2006 4:09 PM
>To: [EMAIL PROTECTED];
Kokotis, Kathy; 'Heather Nichols';
>[EMAIL PROTECTED]; 'Leigh Ann
Bowe-geddes'; [EMAIL PROTECTED]
>Subject: RE: [vascular] RE:
Dilantin
>
>
>
>Did you see Marc's earlier
message today? Lynn
>
>At 5:13 PM -0500 2/13/06, Nancy
Moureau wrote:
>>It would make sense to me
if a drug is a very high pH, such as Dilantin 12,
>>mixed with blood that has a
pH of 7.3, there could be precipitation of the
>>drug if not mixed with
ENOUGH blood. Dilantin infused through a peripheral
>>vein would still maintain
most of the drug integrity, say half Dilantin,
>>half blood, which is why
irritation occurs in the vessel (Dilantin comes in
>>contact with the wall of
the vein), whereas if Dilantin is infused into
>>central circulation or
drips in to a hearty blood flow the full mixture
>>reduces the risk of
precipitate as the Dilantin is less and the blood is
>>more in volume, no
precipitation no irritation. The risk of precipitation is
>>there based with any high
and low pH depending on ratio of each, the more
>>unstable drug would need to
be very dilute thus needing central vein
>>terminal tip location.
>>
>>I agree with Kathy
>>
>>Nancy Moureau, BSN, CRNI
>>PICC Excellence, Inc.
>>888-714-1951
>>www.piccexcellence.com
>>[EMAIL PROTECTED]
>>
>>
>>
>>-----Original Message-----
>>From: Lynn Hadaway [mailto:[EMAIL PROTECTED]]
>>Sent: Wednesday, February
08, 2006 10:57 AM
>>To: Kokotis, Kathy; Heather
Nichols; [EMAIL PROTECTED];
>>[EMAIL PROTECTED];
Leigh Ann Bowe-geddes; [EMAIL PROTECTED]
>>Subject: [vascular] RE:
Dilantin
>>
>>
>>
>>Kathy, I am well aware of
what is stated in Gaharts and Trissels. But what I
>>interpreted from your first
message was not what those references are
>>stating.
>>
>>Yes, phenytoin can
precipitate in a syringe or bag when the pH changes.
>>However, I have never seen
any information in any reference anywhere stating
>>that contact between any
drug and blood inside the vein will lead to a
>>precipitate formation.
>>
>>So yes, precipitate formed
during the administration (tubing, bag,
>>syringe) will end up in the
lungs. But I do not believe that one can state
>>that contact with the blood
in the vein will cause precipitation simply
>>because the pH of the
bloodstream is much lower than the drug. Maybe Marc
>>Stranz can offer his
insights into this issue or maybe I just misunderstood
>>what you were trying to
say. Lynn
>>
>>At 4:12 PM -0700 2/7/06,
Kokotis, Kathy wrote:
>>>Go down to the Pharmacy
and ask them for their copy of Trissels
>>>handbook of injectable
drugs. It is updated yearly and has the info I
>>>just gave you on
solubility. Every pharmacy has a copy
>>>
>>>You will also find the
info I gave you in Gahart Intravenous
>>>Medications by Mosby
which is also updated yearly
>>>
>>>Hope that helps
>>>
>>>kathy
>>>
>>>________________________________
>>>
>>>From: Heather Nichols [mailto:[EMAIL PROTECTED]]
>>>Sent: Mon 2/6/2006 8:13
AM
>>>To: Kokotis, Kathy;
[EMAIL PROTECTED]; [EMAIL PROTECTED];
>
>>[EMAIL PROTECTED]; Leigh Ann Bowe-geddes;
>>>[EMAIL PROTECTED]
>>>Subject: RE: Dilantin
>>>
>>>
>>>Sounds like basic
chemistry to me, but I to would like a reference to
> >>show this, as I
have been making an ongoing case against Dilantin for
>>>some time now here at
my facility. Thanks Kathy
>>>
>>>Heather Nichols RN BSN
CRNI
>>>Infusion Services
>>>University of
Louisville Trauma Institute
>>>530 S. Jackson St.
>> >Lou. Ky.
40202
>>>(502)562-3530
>>>
>>>>>>
"Lynn Hadaway" <[EMAIL PROTECTED]> 02/06/06 9:42 AM
>>>
>>>
>>>Kathy, I must ask for
your reference for this information. Please
>>>provide it or tell us
where you are getting this concept. Thanks, Lynn
>>>
>>>At 7:09 PM -0700
2/5/06, Kokotis, Kathy wrote:
>>>>Dilantin is in some
ways not even compatible with normal saline or
>>>>your bloodstream
>>>>
>>>>Normal saline pH
5.5
>>>>Bloodstream pH 7.35
>>>>dilantin pH 12-14
but if it falls below 10 it precipitates. Both
>>>>blood and normal
saline make the pH fall below 10 so therefore you
>>>>will find crystals
of dilantin in the lungs if it does not
>>>>preceipitate
sooner. Are we not lucky the lungs are a great filter of
>> >>life
>>>>
>>>>Kathy
>>>>
>>>>________________________________
>>>>
>>>>From:
[EMAIL PROTECTED] on behalf of Leigh Ann
>>>>Bowe-geddes
>>>>Sent: Sat 2/4/2006
6:34 AM
>>>>To:
[EMAIL PROTECTED]; [EMAIL PROTECTED]; [EMAIL PROTECTED]
>>>>Subject: Re:
Dilantin
>>>>
>>>>
>>>>Nancy:
>>>>Dilantin is very
prone to precipitation. It is not compatible with
>>>>anything except NS.
Flushing is very important, but there is another
>>>>issue. The lumen
through which the dilantin is infused should be
>>>>dedicated to
dilantin and NS only. Some of the drug may cling to the
>>>>internal lumen, and
if anything other than NS is infused between
>>>>dilantin doses, you
get dilantin crystals in the line. There are some
>>>>other issues with dilantin.
It is very important to flush well, and to
>>>>administer the
medication properly. It is not stable if the pH is
>>>>allowed to drop,
and the normal pH of dilantin is very high, somewhere
>>>>in the 12-13 range.
Leigh Ann
>>>>
>>>>Leigh Ann Bowe-Geddes,
RN, CRNI
>>>>IV Therapy
Specialist
>>>>Infusion Services
Department
>>>>University of
Louisville Hospital
>>>>Louisville, KY
>>>>502-562-3530
>>>>
>>>>>>>
"Nancy Sullivan" <[EMAIL PROTECTED]> 02/03/06 8:26 PM
>>>>>>>
>>>
>>>>
>>>>I know you ladies
and gentlmen have probably discussed this many
>>>>times, but I'm new
to these message baords and have a questions.
>>>>
>>>>My hospital has a
policy that states: "DO NOT INFUSE DILANTIN THRU
>>>>PICC LINES." I
have been working at this hospital for 3 years and it
>>>
>does seem like every time a nurse puts dilantin into a
>>>>picc--occlusion and
loss of the line. I have been told that it is a
>>>>flushing problem
and lack of education. We use groshong and per q
>>>>cath piccs. SO
PLEASE EDUCATE ME IN THIS MATTER, BECAUSE I WOULD LOVE
>>>>TO EDUCATE THE REST
OF THE STAFF. Thanks in advance
>>>>Nancy Sullivan RN
>>>>
>>>>
>>>>________________________________
>>>>
>>>>Yahoo! Mail
>>>><http://us.rd.yahoo.com/mail_us/taglines/virusmail/*http://mail.yahoo.
>>>>com>
>>>>- Helps protect you
from nasty viruses.
>>>>
>>>>
>>>>-----------------------------------------------------
>>>>Confidentiality
Disclaimer
>>>>
>>>>This message,
including any attachments, is confidential, intended
>>>>only for the named
recipient(s) and may contain information that is
>>>>privileged or
exempt from disclosure under applicable law, including
>>>>PHI (Protected
Health Information) covered under the Health Insurance
>>>>Portability and
Accountability Act (HIPAA) of 1996. If you receive
>>>>this message in
error, or are not the named recipient(s), please
>>>>notify the sender
or contact the University of Louisville Health Care
>>>>I.S. helpdesk at
502.562.3637 to report an inadvertently received
>>>>message.
>>>
>>>
>>>--
>>>Lynn Hadaway, M.Ed.,
RNC, CRNI
>>>Lynn Hadaway
Associates, Inc.
>>>126 Main Street, PO Box
10
>>>Milner, GA 30257
>>>http://www.hadawayassociates.com
>>>office 770-358-7861
>>>
>>>
>>>
>>>
>>>-----------------------------------------------------
> >>Confidentiality
Disclaimer
>>>
>>>This message, including
any attachments, is confidential, intended only
>>>for the named
recipient(s) and may contain information that is
> >>privileged or
exempt from disclosure under applicable law, including
>>>PHI (Protected Health
Information) covered under the Health Insurance
>>>Portability and
Accountability Act (HIPAA) of 1996. If you receive
>>>this message in error,
or are not the named recipient(s), please notify
>>>the sender or contact
the University of Louisville Health Care I.S.
>> >helpdesk
at 502.562.3637 to report an inadvertently received message.
>>
>>
>>--
>>Lynn Hadaway, M.Ed., RNC,
CRNI
>>Lynn Hadaway Associates,
Inc.
>>126 Main Street, PO Box 10
>>Milner, GA 30257
>>http://www.hadawayassociates.com
>>office 770-358-7861
>>
>>
>>
>>
>>--
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>>http://www.smartgroups.com/groups/vascular
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>
>--
>Lynn Hadaway, M.Ed., RNC, CRNI
>Lynn Hadaway Associates, Inc.
>126 Main Street, PO Box 10
>Milner, GA 30257
>http://www.hadawayassociates.com
>office 770-358-7861
--
Lynn Hadaway, M.Ed., RNC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
