040: Assessment of Clinical Challenges With Application of Institute for Safe Medication Practices Targeted Medication Safety Best Practice: Injectable Promethazine

Statement of Purpose, Innovation or Hypothesis: Postoperative nausea and vomiting (PONV) represent a patient-important outcome in anesthesia practice.  PONV is ranked as more distressing than postoperative pain, can impact patient outcomes and is common after surgery. Despite the availability of various antiemetics in several therapeutic classes, the management of PONV remains a challenge. Many institutions are still utilizing injectable promethazine due to its efficacy as an antiemetic despite safety risks of severe tissue injury and possible respiratory depression. Furthermore, given the limitations in literature and other considerations related to the use of more recent antiemetic agents and safety concerns with historical agents in pediatric patients, novel therapeutic options are minimally used in this setting.

Description of Methods & Materials: To assess the institutional use of injectable promethazine, data from dispensing administration records (Discern Analytics) was pulled from October 2021 until April of 2022. Data collected included: service line ordering, how medication was ordered, number of doses administered, route of administration (central versus peripheral), and alternative antiemetics utilized.

Data & Results: During the time interval of assessment, postoperative PONV management by anesthesia was the highest prescribing service line of injectable promethazine (56%). Furthermore, a majority (80%) of administrations were via a peripheral line, which potentially has a higher incidence of safety complications. Despite this, zero safety incidences were found via chart review.

Interpretation, Conclusion or Significance: ISMP medication safety best practice suggests eliminating injectable promethazine from the formulary.   Literature review demonstrates that in patients who fail ondansetron prophylaxis, promethazine is more efficacious than redosing ondansetron or another 5-HT3- antagonist, Combination PONV rescue treatment is more efficacious than single-agent rescue treatment. While the efficacies of most treatments were demonstrated through one or more randomized control trials, the certainty of the conclusions reached by the available evidence ranges from moderate to very low. Considering the importance of effective PONV rescue treatment and patient safety in clinical practice, particularly in patients who fail prophylactic intervention, more high-quality studies are needed in this area.

Disclosures: None

Citations/References: 1. Promethazine. In: Lexi-Drugs Online. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  2. Southard BT, Al Khalili Y. Promethazine. [Updated 2022 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544361/. 3. Promethazine hydrochloride injection [package insert]. Irvine, CA: Teva Pharmaceuticals, Inc.; 2009.  4. Josko Markic, Anna Louise Ridge. Promethazine in the treatment of postoperative nausea and vomiting: a systematic review. Signa Vitae. 2011. 6(2);9-16.  5. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and management. Am Health Drug Benefits. 2012 Jul;5(4):232-40. PMID: 24991322; PMCID: PMC4046471.

Additional Information/Authors: None