What would cause destabilization after it enters the bloodstream?
Maybe things like too rapid injection or very low blood flow?? Or
could there be chemistry changes in the patients blood that would
produce this? Just curious, Thanks, Lynn
At 4:39 PM -0600 2/14/06, Stranz, Marc wrote:
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
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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
>>>
>>>
>>>
>>>
>>>-----------------------------------------------------
> >>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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>
>--
>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
--
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 Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
