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nanmal
Use of hand and wrist veins
I am the PICC nurse in a small community hospital.  My home department is Daysurgery.  Because one of our general surgeon practices wants to continue to use IV phenergan, we have been forbidden to insert IVs in surgical patients in the wrist or hand unless absolutely last resort. Our phenergan policy is that it must be given in a large peripheral vein outside the wrist or hand, otherwise it must be diluted in 500 ml of saline.  My question is, do any other institutions out there forbid use of hand or wrist veins?  I know that either site is not ideal for many reasons, however this new policy seems extreme.  Any feedback on this?  It would be greatly appreciated.
lynncrni
It is definitely ***not***

It is definitely ***not*** extreme. I would also add the antecubital fossa to the list of prohibited sites for administration of this drug! I have been the expert in numerous cases involving many serious complications from promethazine including amputation. They were all given in sites of joint flexion. INS standards have always said to avoid these sites for administration of all catheters, but it is especially important for vesicant meds. If there is absolutely no way to avoid using a vein in these locations, you must stabilize that joint with an arm board, also in the INS standards. I am not convinced that the higher dilution as you mentioned is any safer. In fact, this could also add additional risk if the catheter erodes through the vein wall and fluid begins to escape during the infusion, and the nurse is not there to be frequently assessing this site. Promethazine requires the same level of expertise required to given any vesicant antineoplastic drug which includes small catheter gauges, avoid site of flexion, adequate stabilization preferably with a manufactured stabilization device, thorough site assessment before each dose, flushing, free flowing gravity drip, no injection through a heparin lock, mandatory blood return check before, during, and after injection, with all of this documented. Of course, the best thing would be to prohibit IV doses of promethazine altogether. One other thing - contact between the drug and blood changes the appearance of the blood. So if you are accidentally in an artery, the bright arterial blood will appear as dark venous blood, leading the nurse to think that they are in the vein. This is one reason to avoid the ACF. If I were a patient, I would absolutely refuse to receive this drug. It carries too much risk especially since the nurses giving it are not knowledgeable, skilled infusion specialist. 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

nanmal
Thank you for your reply. 
Thank you for your reply.  I realize phenergan should not be given in these areas...my question was mainly for general venous access, unrelated to phenergan.  These physicians are just using phenergan as the reason to avoid hands and wrists...So what is your recommendation for the elective surgery patient where we cannot find a forearm vein?  My boss thinks inserting a midline for a Daysurgery patient wouldn't be unrealistic.  And our anesthesiologists do not like for us to access the antecubitals.  With so many older and more obese patients, what is the answer if we cannot use hands or wrists?  What does your institution do for their Daysurgery patients?
lynncrni
As I mentioned, sites in an

As I mentioned, sites in an area of joint flexion have always been included in the standards as a site for extreme situations. You can be trained on using ultrasound for these difficult patients. There is also the use of infrared light technologies for locating veins in patients with difficult access. You can use the hand or wrist in an patient where no other site can be found if you support the wrist with an arm board. Just don't give vesicants like promethazine through these sites.  

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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