Thanks for sharing this case. This supports what we have always
known about the pH and vein wall damage. However I am still
questioning the concept that precipitate will happen when Dilantin
hits the bloodstream. This would also cause vein wall damage in the
form of phlebitis just like other particulate matter and would end up
in the patients lungs. So I guess we will not have an answer to this
until we have a study of lung biopsies during autopsy after someone
has received lots of IV Dilantin. There is no question to me that it
is a nasty drug and fosphenytoin should be used, so I hope the
precipitate question becomes unimportant. Lynn
At 7:35 AM -0500 2/15/06, Heather Nichols wrote:
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I had a patient over the summer who was a healthy adult male, (until he flipped his 4-wheeler and caused himself a nice large boo boo on his wittle head), come into the ER and receive a bolus of Dilantin peripherally. The peripheral was an 18g that was put into the median cubital vein (very large vein) by the ER nurse. I happened to be on hand a little later and was called to place another site because the ones they were placing "kept blowing and infiltrating". I informed them nicely that the sites were extravasating, not infiltrating, and this fella already had red streaks up and down both arms due to the bolus of Dilantin, which they had not yet even been able to finish. The doc would not allow a central line at this time. He was transferred to the floor later that evening, and the first dose of Dilantin was ordered. Before it was given, I scanned his arms with the ultrasound. His basilic, brachial, median cubital, and cephalic on the right were full of thrombus and uncompressible. His left was better, but there had been less IV sites on the left. I showed the doc. I showed the ER doc. This was caused by only a bolus, not several uses. They put in a central line, and now our ER only boluses with fosphenytoin, then puts in a central access before changing to Dilantin. Why did it take this happening to this poor kid? I would have killed someone had he been mine. Dilantin is bad news peripherally. One or two still slips by us occasionally, but for the most part, the docs here are pretty good about it now. Thank God!
Heather Nichols RN BSN CRNI
Infusion Services
University of Louisville Trauma Institute
530 S. Jackson St.
Lou. Ky. 40202
(502)562-3530
>>> "Martha Pike" <[EMAIL PROTECTED]> 02/14/06 10:11 PM >>>
again, I have seen and felt it happen in real time in a real patient
/Martha
On Feb 14, 2006, at 10:18 AM, Lynn Hadaway wrote:
> 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.
>>>>>
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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
>>>>
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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
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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
>
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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 Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
