Severe Tissue Injury with IV Promethazine

The Institute for Safe Medication Practices recently warned that administering promethazine parenterally may cause more severe tissue injuries than previously recognized. Promethazine, which is commonly sold under the trade name Phenergan, has many uses including as an antihistamine, a sedative and an antiemetic.

ISMP points that out promethazine is a known vesicant which is highly caustic to the intima of blood vessels and surrounding tissue. Deep intramuscular injection into a large muscle is the preferred parenteral route of administration, and is least likely to cause damage. But promethazine is also given by slow IV push in many hospitals. The IV route, along with inadvertent intra-arterial or subcutaneous administration is most likely to result in significant complications, ranging from burning and pain to paralysis, tissue necrosis, and gangrene. Sometimes surgical intervention such as fasciotomy, skin graft or even amputation is needed.

ISMP describes several recent cases where severe tissue damage occurred following IV administration of promethazine. For example, in one case a 19-year-old woman who went to the emergency department with flu-like symptoms was given Phenergan IV. During the injection, she cried out in pain, and after the injection she told the nurse that her arm was still in significant pain and that she felt "something was wrong." The nurse reassured her and then left the room. The patient's arm and fingers became purple and blotchy and then over the next several weeks eventually turned black and shriveled. Her thumb, index finger, and top of her middle finger eventually had to be amputated.

ISMP points out that the product labeling makes several recommendations to reduce the risk of these adverse events. They include giving the drug in concentrations no greater than 25 mg/mL, administering the drug at a rate no greater than 25 mg/minute, injecting the drug through the tubing of an infusion set that's running and known to be working satisfactorily, and stopping the injection immediately if the patient reports burning in order to investigate whether there might be intra-arterial placement or perivascular extravasation.

In addition to the manufacturer's recommendations, ISMP lists about a dozen other strategies to prevent or minimize tissue damage when giving IV promethazine. Here are several suggestions.

• 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 patient'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.

FDA Patient Safety News: February 2008

For more information, please see our website:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=72#5

Category:

Education

Tags:

• phenergan
• severe
• tissue
• injury
• IV
• promethazine

[LiLAfRoDuDe96]

If you want to see how promethazine has effected my dad, go to his channel timjames6 and watch his it ain't over till it's over video

[kmcl11]

I find it odd that when given IM, the side effects aren't as bad as IV.

[thedandc]

I always piggyback a 100ml bag of normal saline at a slow drip and inject 1ml slowly into it the bag over a 5 minute period.

[Scotchtwin18]

Our hospital is now requiring we dilute in 50ml or 100ml bags and drip in slowly. We just use the snot out of zofran.

[tdeal31]

Phenergan needs to be diluted with 10cc of normal saline, and pushed SLOWLY into a patent IV site. We try to use Zofran instead.

[NightOwl30]

believe me this is very real! I had pneumonia and was in the hospital for 6 days, 4 days of which I got IV Phenergan for nausea. The IV burned and they had to change sites about 2 times. Four days after being out of the hospital my arm is still hurting. It did swell up and get red and hot but has gone down.

[lanepmcbeal]

thank you for sharing this information...

[ohashky]

thank u

[ziema75]

good video very infomative thanx

[mobitz57]

This is a great resource! Thanks for the vid!