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A patient recovering from a craniotomy needed phenytoin (Dilantin) to prevent seizures. The patient's nurse, preparing to administer the 9 a.m. dose of Dilantin, checked the doctor's order. The order stated that the dose could be given either through the patient's nasogastric (NG) tube or intravenously.
Because the NG tube had become clogged earlier, the nurse decided to give the dose intravenously. She attached a volumecontrol set to a bottle of 5% dextrose in water, filled the set with 50 ml, and added the Dilantin. She started the infusion and continued on her medication rounds.
Just a few minutes later, she heard the alarm from the infusion controller sounding in the patient's room. When she returned to the room and checked the I.V., she saw that the line had stopped infusing. She flushed it with saline and left again to administer the rest of her medications.
She was barely out of the patient's room when she heard the alarm sound again. This time she checked the I.V. line very carefully ... and was horrified to see crystals forming along the entire length of the tubing.
The nurse immediately stopped the infusion and called the pharmacist. He told her Dilantin and dextrose were incompatible and that mixing them caused the crystallization. He explained that Dilantin should be given by a slow I.V. push.
The nurse checked with the doctor, who okayed the I.V. push. The patient suffered no "ill effects from the incident.
The nurse could have prevented this error by reading the package insert for Dilantin, which warns against mixing the drug with any I.V. solutions. The insert recommends only a slow I.V. push of 25 to 50 mg/minute. In fact, recent studies recommend no more than 40mg/minute.
In many hospitals, a large dose (up to 1 gram) of Dilantin is diluted in normal saline solution before it's administered. But this method isn't officially recommended. Whatever you do, though, don't mix Dilantin with dextrose solution.