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An 89-year-old former stroke patient was admitted with a diagnosis of myocardial infarction. When she developed seizures, her doctor ordered several medications, including Dilantin (phenytoin), 100 mg, slow I.V. push, every 8 hours.
The patient was already receiving an infusion of D5 W in her right hand. Because the patient's veins were so fragile, the nurse didn't want to start another I.V. So, knowing that combining Dilantin with dextrose can cause precipitation, she diluted the drug with 10 ml of saline injection. After flushing the running I.V. with normal saline solution, she slowly injected the Dilantin through the Y site, then flushed the line again.
An hour later, the nurse observed signs of severe phlebitis in the patient's right hand. She alerted the doctor, who ordered a continuous infusion of heparin at 1,000 units/hour. The hand was saved, but the patient had to be hospitalized for 10 days of heparin therapy.
This medication error shows just how incompatible Dilantin and dextrose are. Even though the nurse diluted the Dilantin and flushed the line with saline, a precipitate still formed. The patient's small veins and decreased peripheral circulation undoubtedly contributed to the severity of the reaction.
When administering I.V. Dilantin to a patient receiving D5W, be careful not to repeat this nurse's mistake. The only way to prevent precipitation in this case is to inject the Dilantin directly into a large vein or into a running infusion of normal saline.