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Dilantin occlusions in PICCs

How are people infusing their dilantin? Is it possible to safely administer through central line/PICC without causing occlusion from precipitate? How?

Have been infusing dilantin through peripheral vein and using up all of the patients veins from phlebitis while patient has PICC in place. If nurses use the PICC they plug it up with precipitate within one to 2 days. Any suggestions? We are using Groshong PICC 4 and 5 fr. What also about infusing through percutaneous catheters? especially if using heparin to lock off lumens--does the heparin residual lead to precipitate formation as well?


 We infuse with filter and

 We infuse with filter and prefer PICC or central line. Too much risk of tissue damage with infiltrate. In fact it is on our drug search list for IV team nurses to pursue the MDs to give it in the gut or get a PICC/other central line in. Most of the time the only peripheral infusions we see are loading doses in the ED.


Jose Delp RN BSN

Clinical coordinator IV Team

Upper Chesapeake Health

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

I agree, If you push

I agree, If you push dilantin than use 20-30ml NS, if you use the drip, you have to flush the central line or the picc every hour with at least 10ml NS to keep it open. Best way is PIV.


If you are using a
If you are using a peripheral IV are you not losing access quickly from phlebitis? Fortunately have never seen an extravasation of dilantin but expect that is still to come. I am in an acute care teaching facility with large neuro unit so lots of people receiving dilantin IV for prolongd periods of time.

Patrice Wilken RN

Vascular Access Team


 The best solution is to

 The best solution is to quit using intravenous Dilantin entirely.  We used Groshong PICCs exclusively for several years, and if Dilantin was infused through the line, it inevitably plugged up in a couple of days.

Dilantin is a vesicant, so when given through a peripheral IV it causes phlebitis.  If it extravasates, it can cause major harm.  A safe alternative, Fosphenytoin, is readily available, though a bit pricey.  The key is convincing the people in charge that avoiding injury to the patient and avoiding potential multimillion dollar lawsuits is worth the added cost of the drug. 

Like Kathy Kokotis told us, you don't want to be the one on the witness stand explaining why the patient was given the Dilantin that ate away part of their arm when you could have given them something safe for a few dollars more.

Jerry Bartholomew RN, BSN, CRNI

VA Medical Center, Spokane, WA

Jerry Bartholomew RN, MSN, CRNI

VA Medical Center, Spokane, WA

Get rid of Dilantin if

Get rid of Dilantin if possible and switch to an alternative drug

If you cannot do that than make sure you use a 20cc saline flush and don't use the heparin.  You cannot let the dilantin pH fall below 10 and normal saline is 5.6.  Flush gets the dilantin out of the line but you need enough flush 20-30cc of saline.  Use the biggest lumen of your PICC.  If you have a Triple use the purple middle lumen.  If it is a dual lumen find out which lumen is bigger (all manufacturers are not the same).  If you have a single lumen never use less than a 4 french.  Internal volume will matter and length of PICC will as well.  Anything that slows the flow matters.  Dilantin cannot become stagnant as it will precipitate.  Good luck 





Kathy Kokotis

Bard Access Systems

Are you saying that in a

Are you saying that in a shorter larger bore percutaneous central line the flow wouldn't be as diminished as in a longer PICC so less chance of precipitate formation? We are using heparin 100u/ml to lock off our CLs--would the heparin lead to precipitate as well?

We have been talking about fosphenytoin for years but it is still not available for use in our adult population--yet seeing more  people on IV dilantin for longer periods of time--so trying to come up with plan for advocating for our patients and getting the best line in with the best patient outomes.

Thanks for your help

Patrice Wilken RN

Vascular Access Team


What also about infusing
What also about infusing through percutaneous catheters? mephisto sandals | sanuk sandals | naot sandals
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If there is one thing that
If there is one thing that was drummed into our heads in nsg school (a bazillion years ago) it was this DO NOT MIX DILANTIN AND ANY DEXTROSE.  NO D5 NO D5 1/2  or any other variation that has dextrose.  It is the dextrose that precipitates with the dilantin.  Since Dilantin is not used as much as it used to be, a lot of people aren't aware of this. Even though everyone knows that you h ave to flush with saline, if you inject into a primary line that has D5 1/2, it will precipitate.  Period.  I'm always surprised at how many nurses are not taught this. 
Use fosphenytoin.   Mari

Use fosphenytoin.


Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

When my organization used

When my organization used Groshong we had the same issue infusing Dilantin. Non-silicone PICC users do not understand this as is evidenced from so many responses asking if your nurses were administering it correctly. When we added PowerPICC to our choices of lines we discovered that the Dilantin infused quite well through the polyurethane line. Our conclusion was that there was some sort of issue between the silicone material of the Groshong and the chemcical properties of the Dilantin. This might be why we don't see the clogging issues with traditional short CVC lines since they are all polyurethane. However, even though the dilantin infuses fine through the catheter we did discover that Dilantin levels drawn through the same port could be falsely elevated. Apparently the drug can still leach into the catheter material over time.

You DO NOT want to give the Dilantin through a PIV so my suggestion is either change to a polyurethan catheter, which seems extreme given the small numbers of patients who get Dilantin IV or do as the others suggest and change to another med for those patients with PICCs. It shouldn't be that big a cost to the institution if you only use the fosphenytoin on your PICC patients (although I am not sure providers/nurses will remember which drug to order if both are still available.)

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