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Take steps to avoid inadvertent IV administration of nimodipine

From the July 28, 2005 issue

NIMOTOP (nimodipine) is a calcium channel blocker indicated for patients with subarachnoid emorrhage. It improves neurological outcome by relaxing cerebral smooth muscle vasculature and preventing vasospasm, thus reducing the incidence and severity of ischemic deficits. The drug is available in a soft gelatin capsule and normally given orally. The manufacturer, Bayer, notes in the product labeling that, in patients who are unable to swallow and have a nasogastric (NG) tube in place, doses can be prepared by extracting the contents of the capsule into a syringe with an 18-gauge needle, administering it via the NG tube, and flushing with 30 mL of saline. However, as noted in our August 25, 1999 issue, this procedure is potentially dangerous, as there have been several reports in which the drug was drawn into a parenteral syringe and accidentally given IV, resulting in severe hypotension, cardiovascular collapse, and cardiac arrest.

A recently reported event demonstrates that recommendations for preventing this error are
WorthRepeating. A pharmacy dispensed nimodipine capsules to nursing units, unaware that these were being used for patients who couldn’t swallow. Thus, the pharmacy had not provided instructions on how to prepare the capsule contents for feeding tube administration, or to flush the dose with 30 mL of saline. In one instance, a nurse softened the gelatin capsule in hot water and subsequently with drew the medication into a parenteral syringe. In the chaos of the day, the dose was administered IV instead of via the feeding tube. The nurse immediately noticed the error and tried unsuccessfully to withdraw the drug from the IV tubing. Unfortunately, the patient decompensated almost immediately and subsequently expired.

In light of this event, the pharmacy has now created a new drug entry in the computer for nimodipine 30 mg/mL oral product with default comments that doses given via NG tube should be flushed with 30 mL of saline after each administration. The new entry produces a label for use with amber oral syringes stocked in the pharmacy. According to a recent study (Green AE, et al. Stability of nimodipine solution in oral syringes. Am J Health-Syst Pharm 2004; 61:1493-6), nimodipine liquid extracted from capsules, stored in amber oral syringes and placed in light-protected bags, is stable at room temperature for 31 days. Thus, the hospital prepares nimodipine syringes in batches; each amber oral syringe contains a "use by" date of 30 days from production and is stored in an amber plastic bag with a sticker "FOR ORAL (NG) USE ONLY." For safety reasons, we also recommend notifying pharmacists if patients cannot swallow so such a process can be implemented. Keep in mind that, while someNG tubes have a connection that is notcompatible with an oral syringe, others are available with a suitable port that iscompatible. Therefore, the style of NG tube should be investigated before implementing this procedure or nurses may have to empty the oral syringe into a parenteral syringe, thus defeating this safety measure. Since this error has occurred numerous times with fatal results, whenever nimodipine is dispensed, it is critical that pharmacy communicate the potential danger of inadvertent IV injection directly to the person responsible for administering the drug. A reminder in the computer and on the drug container and product labeling may trigger this response.


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