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Avoid Intravenous Promethazine (Phenergan) When You're Nauseous or When You're Getting a Pain Shot

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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 patientÂ?s 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:
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MPEG Download (e.g. iPod)


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About the Author


MD, FACP, FASN

Dr. Schwimmer's blog explores the intersection of medicine, new technologies, and the Internet.

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