High Alert Medication

Anticonvulsant

CCP: Seizures refractory to midazolam

• Sinus bradycardia, sinoatrial block, 2nd or 3rd degree AV block, Adams-Stokes syndrome, QT interval prolongation, or other heart rhythm disorders
• Hypersensitivity to phenyTOIN or other hydantoins
• Hypersensitivity to propylene glycol or ethanol
• Concurrent poisoning or toxic ingestion (cyclic antidepressants, cocaine, etc.) 

Intravenous:

• Onset: 30 minutes - 1 hour
• Peak: 1-2 hours
• Duration: 24 hours

• Cardiovascular: Cardiac arrhythmia, cardiac conduction disturbance (depression), circulatory shock, hypotension, ventricular fibrillation
• Central nervous system: Ataxia, cerebral atrophy (elevated serum levels and/or long-term use), cerebral dysfunction (elevated serum levels and/or long-term use), confusion, dizziness, drowsiness, headache, insomnia, nervousness, paresthesia, peripheral neuropathy (associated with chronic treatment), slurred speech, suicidal ideation, suicidal tendencies, twitching, vertigo
• Dermatologic: Bullous dermatitis, exfoliative dermatitis, morbilliform rash, scarlatiniform rash, skin or other tissue necrosis, skin rash
• Endocrine & metabolic: Decreased T4, increased gamma-glutamyl transferase, vitamin D deficiency (associated with chronic treatment)
• Gastrointestinal: Constipation, dysgeusia, gingival hyperplasia, nausea, swelling of lips, vomiting
• Genitourinary: Peyronie's disease
• Hematologic & oncologic: Macrocytosis, megaloblastic anemia, pseudolymphoma, purpuric dermatitis
• Hepatic: Acute hepatic failure, hepatic injury, hepatitis, increased serum alkaline phosphatase, toxic hepatitis
• Local: Injection site reaction ("purple glove syndrome;" edema, discoloration, and pain distal to injection site), local inflammation, local irritation, localized tenderness, local tissue necrosis
• Neuromuscular & skeletal: Osteomalacia
• Ophthalmic: Nystagmus
• Miscellaneous: Fever, tissue sloughing

High Alert Medication

• PhenyTOIN must be infused slowly.  Do not exceed an infusion rate in adults of 50 mg/minute, and 1-3 mg/kg/minute (or 50 mg/minute, whichever is greater).  Hypotension and severe cardiac arrhythmias may occur with rapid administration and have been reported even when infused below recommended rate.  Cardiovascular monitoring is mandatory during and after phenyTOIN administration. 
• PhenyTOIN is a vesicant and can cause significant tissue damage if extravasation occurs.  Ensure line patency during infusion. 
• Ensure that an in-line micron filter is used during administration of diluted solution to prevent infusion of phenyTOIN crystals.
• PhenyTOIN is incompatible with dextrose solutions and will precipitate very rapidly. 
• Do not attempt to administer phenyTOIN through PICC lines.