Avoid Intravenous Promethazine (Phenergan) When You're Nauseous or When You're Getting a Pain Shot
Wednesday, December 06, 2006
Enoch Choi
The FDA has been highlighting the Institute for Safe Medication Practices warnings, who recently warned that administering promethazine intravenously (in a vein) may cause more severe tissue injuries than previously recognized. Promethazine, known by the trade name Phenergan, is most used as an antiemetic (anti nausea & vomiting) in conjunction with a narcotic pain reliever, but also has uses for its antihistamine and sedative effects. You'd most likely encounter it when you go to the Emergency Room or Urgent Care (like where I work) and may require an antiemetic for vomiting and dehydration, or to prevent those side effects from happening while receiving injectable painkillers. That's why I'm bringing it to your attention, so you can ask for it to be given to you intramuscularly or to consider asking for a different medication.
Although promethazine is a known vesicant which is can damage blood vessels and surrounding tissue it is commonly used intravenously. Deep intramuscular injection is the preferred kind of injection, and is least likely to cause damage. Starting in residency, physicians are taught that promethazine can be given by slow IV push, say, over 5 minutes. Unfortunately, this IV route can put you at risk of injecting it into an artery or into your tissue rather than a blood vessel, resulting in possible serious complications, ranging from pain to paralysis, tissue necrosis, and gangrene. Recent cases highlight complications requiring fasciotomy (releasing the capsule around a muscle because of swelling), skin graft (transplanting over removed dead skin) and amputation.
Please click on the video links below to see graphic pictures of one case where a 19-year-old woman who went to the emergency department with flu-like symptoms was given Phenergan IV. The video shows how she complains of pain, but is told by the nurse that her arm was fine. The patient's fingers became dark and then turned black and shriveled. Her thumb, index finger, and top of her middle finger had to be amputated.
For these reasons and others, many Emergency Departments have switched to using other anti-nausea antiemetics rather than take the risk of complications. You could limit your risk by asking for a different drug, or consider the following good recommendationss which were noted by ISMP to minimize the risk of problems:
- Stop if there's any discomfort
- Check that the IV is running into your vein and not extravasating into your tissue, then inject slowly, not faster than 25mg / minute
- Stock promethazine only in the 25 mg/mL concentration (not the 50 mg/ml) since this is the highest concentration of promethazine that can be given IV.
- Consider 6.25 to 12.5 mg of promethazine as the starting IV dose, especially for elderly patients.
- Give the medication only through a large-bore vein and check the patency of the access site before administering.
- Administer IV promethazine through a running IV line at the port furthest from the patientÂs vein.
- Consider administering IV promethazine over 10-15 minutes.
- Before administering the drug, tell patients to let you know immediately if burning or pain occurs during or after the injection.
Source quoted by FDA:
ISMP Medication Safety Alert! Serious Action needed to prevent serious tissue injury with IV Promethazine. August 10, 2006
Videos:
Windows Media, closed captioned
Real Player, closed captioned
MPEG Download (e.g. iPod)
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9 Comments:
At Wed Mar 21, 10:02:00 PM 2007,
Anonymous said…
Very True!!! I love phenergan and it was a necessary drug to take along with my IV Demerol to counter act the fact that Dem alone will make me vomit.
I had severe gall bladder disease, a stone got out, blocked a duct, led to pancreatitis. Anyway I was in the hospital for four days getting prometh every 6 hours or so and it blew every one of my veins. I had huge bruises all over. I wish I would have known to ask them to give it to me IM. Too bad I didn't see this sooner! :)
At Thu Mar 22, 06:17:00 PM 2007,
Anonymous said…
I also was given phenergan iv with an ER visit for my vomiting. In fact I was given several doses into my IV but did not stop my nausea. Then they gave me another drug usually used for chemo nausea & it worked.
Also the whole staff said my chest sounded great-lungs clear. Right before leaving had x-ray. I had a really good case of peumonia.
If I have to have nausea meds I will ask not to be given phenergan IV. I had no problems from this so guess I really was blessed
At Sat May 12, 06:02:00 PM 2007,
Anonymous said…
after reading these stories i'm pissed.Why you ask ?Why if you have been diagnosed with gall stones don't doctors know the problems.Seams simple dosen't it?
At Sun Jun 17, 10:28:00 AM 2007,
Anonymous said…
I am a registered nurse & worked in Surgical ICU for 25 yrs. One of my most memorable patients was a young woman being treated for gallstones, back in the early 1990's. She was on the med-surg floor & was administered IV Phenergan in an infiltrated IV (one that has become out of the vein & is in the surrounding tissue). She almost lost her right hand. A plastic surgeon had to come in & do a fasciotomy on her hand in the middle of the night, due to the gangrene. She spent a month in our unit; we even had to put leeches on her fingers to induce blood flow! I'm glad to see the press is responding to what we used to think was a "harmless" drug. Because of this incident, this plastic surgeon, has never ordered IV Phenergan for any pt.
pambrad
At Sun Jun 17, 10:33:00 AM 2007,
Anonymous said…
I am a registered nurse & worked in surgical ICU for 25 yrs. One of my most memorable pt's was a young woman being treated for gallstones in the early 90's. She was on the med surg floor & a nurse gave her IV Phenergan in an infiltrated IV, one that has come out of the vein into surrounding tissue. She had to have a plastic surgeon come in & do a fasciotomy on her R hand in the middle of the night, due to the gangrene. We even had to put leeches on her fingers to induce blood flow. She came close to losing that hand. I'm glad to see the press responding to what weused to think was a "harmless" drug. I would definitely question this practice, if a dr. pordered it, again!
At Mon Mar 10, 12:12:00 PM 2008,
Anonymous said…
February 22, 2008 I had a vaginal hysterectomy. Pre-surgery I was given Phenergan via an IV placed on the top of my hand. The pain as the medicine went in was horrible - it burned like crazy and I was groaning in pain telling the nurse.
I was released February 23, 2008. The day I got home my hand was swollen all the way to my elbow. I had no knuckles and no wrist. My arm hurt to the touch - even putting a shirt on still causes major pain.
I called my doctor a few days later and was told that swelling was to be expected.
Needless to say I have been to the emergency room twice for the swelling only to be told there's nothing they can do. The main vein in my had is dark green, standing up, and very rubbery feeling. Now I have 5 other veins on the top, bottom and side of my arm that are sticking up, greenish/purplish in color, rubbery and I am still in pain.
The last time I had to deal with the swelling was March 3, 2008 but the pain continues.
One ER doc told me that the main vein in my hand is dying and will never work again. Is there any help for this or do I wait until it's time to amputate my fingers??
At Fri Jul 11, 12:12:00 PM 2008,
Anonymous said…
I was taken to the ER for vomiting and dehydration. I was given Zofran a few times, but that did not work and so the doctor put me on Phenergan via peripheral IV in my right hand. I have never had so much pain before. I almost felt like telling the nurse that I would continue vomiting rather than taking the pain. It has been three weeks since I have been discharged and I still have sharp pain in my hand. I cannot grip drinking glasses nor lift weights properly. Please be careful. I know it is hard to read up on drugs that you have not used yet or do not think you will need, but be aware of this one!!
At Tue Aug 05, 11:30:00 AM 2008,
Anonymous said…
The original author should have pointed out that MANY drugs will cause tissue necrosis if given into an infiltrated IV. Many drugs will cause necrosis and possible severe tissue damage if given mistakenly into an artery. So the main problem is not necessarily the drug, but proper care and monitoring of intravenous lines.
Phenergan is not usually a first line drug, not only because of tissue toxicity, but also because of sedative properties. Unfortunately, sometimes anti-nausea drugs with fewer side effects simply don't work. Compazine (prochlorperazine) has been promoted by some as an alternative, but it also can cause tissue damage, and has a higher risk of extrapyramidal side effects.
Giving phenergan intramuscularly does not allow for gentle dose titration, which helps avoid overdosage. I have seen people stop breathing who have been given too heavy a dose of IM sedating phenergan in conjuntion with respiratory depressing narcotics.
All drugs have side effects. It's likely that millions of doses of phenergan have been given I.V., so although the horror stories are good to keep in mind, they shouldn't dissuade those who truly need the drug, provided that it is given in a safe fashion.
At Fri Aug 08, 08:33:00 AM 2008,
Amanda said…
When I was pregnant with my first child, I went into labor 28 times starting at 5 months. I was given Brethine to help stop contractions (its a steriod), but b/c of the pain, pressure, and obvious anxiety I could not relax enough for the drug to do its work. I was given Stadol to help control the pain, and Phenergan was given along with it, all 28 times. I am a nursing student, and I know what the IV is suppose to look like and where it is suppose to go. I NEVER EVER EVER had a problem with the drug Phenergan. I had cardiovascular issues with all of the Brethine Sub Q in my arm (blood pressure and heart rate to be exact) I was given to keep my preterm labor under control, but never b/c of the phenergan. All drugs have side effects.... which means a few people will have serious problems with them. Some people are more sensitive, especially if they do not take many medications. Other people's body may have a hard time breaking the medicine down or the immune system may reconise it as dangerous and attack it. I am a firm believer in Phenergan for the simple fact that Stadol is such a strong narcotic, I was nausous with 25 mg of Phenergan. I didn't ask for more, I could handle the nausea after the IV. I think that instead of blaming the drug or the doctor's who order it, the patients need to ask the nurse to ALWAYS check the IV before they push anything into it. It is not the nurses' fault if the patient moves or pulls on the tape and moves the IV out of the vien. Even though every nurse should check before they push drugs into the IV, the patient (if able) should be an active part in their health care.
Amanda
lilhayden20@yahoo.com
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