Vanco peak and troughs, what's your policy?

  1. A question came up yesterday. At my facilty you get the trough right before the vanco dose, then start up the vanco dose. The peak was due to be drawn 1/2 hour after the dose was in. The doc had ordered it done on the 2200 dose. One nurse challanged me because I didn't hold the vanco until after the trough came back. He's worked elsewhere, I work with him in ICU, but this was a Med-Surg pt that I was handing over after 4 hours, after having floated.

    Anyways he said that he always waits to start the vanco until after the trough is back, that it was protocol where he worked before. I discussed it with other co-workers and traditionally where I work we start up the vanco immediately, leaving the trough and peak for pharmacy and the doc to evaluate. I discussed it in the morning with yet another co-worker and we all agreed that perhaps we need clarification on this.

    What is the policy where you work? Any opinions? We are going to bring up this question with pharmacy and our manager.
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  2. 13 Comments

  3. by   rehab nurse
    hi garden dove. where i used to work we drew the trough (with a BUN/cr too) an hour before dose was due, then hung the drug. we didn't wait till the results came back. (of course that was in a rehab unit offsite from the hospital, likeLTC).

    our labs were faxed to us on the floor and directly to the pharmacy too, so they could order a different dose or maintain them.

    HTH.

    and this was the orders from our docs as well. that was our policy.
  4. by   Larry77
    We do not get the trough results before we hang the Vanco, and we no longer do peaks at all. The doses are adjusted by a pharmacist who's only job is to go to all the floors and adjust the high potency ABO's and he does this by the trough's. Usually we only here about the trough if it is a critical value then we would stop the vanco until further orders.
  5. by   ZASHAGALKA
    Trough 1/2 hr before, peak 2 hrs after, don't hold the drug.

    ~faith,
    Timothy.
  6. by   GardenDove
    In this case the trough was high but not critically. The vanco was infusing already when I got it back. I was handing over the pt and we were all in report together. This fellow is great, but he has an argumentative manner, and is cocky, and you just have to argue back with him sometimes. He and I get along great. Then I went to my co-workers to see what they thought, and they agreed that they handled it the same way as I did. We agreed that maybe we need to bring this up to pharmacy, and management for a review of how we are handling this.
  7. by   TiffyRN
    I've seen it done both ways. It's just what the docs at your facility like done. Currently where I work we draw the trough 1 hr before and wait for the results before we start the dose. Problem is; lab takes their time and harassing them doesn't help so we wind up drawing the troughs 1.5 hrs before so we have the results. I work with neonates so I think it's more important to make sure the level isn't toxic.

    I liked it best at another facility I worked for that pharmacy took care of dosing IV aminoglycosides (with md order). They rarely did a traditional peak and trough. Most of the time they would order a 10hr post dose level and also a BUN/creatnine. They would plug those numbers into a computer program and it would adjust the dose (or not). They used very non-conventional doses and times; like Vanco 1275mg q30hrs; or Gent 135mg q16hrs (not babies; these were adults).
  8. by   paccookie
    Quote from GardenDove
    A question came up yesterday. At my facilty you get the trough right before the vanco dose, then start up the vanco dose. The peak was due to be drawn 1/2 hour after the dose was in. The doc had ordered it done on the 2200 dose. One nurse challanged me because I didn't hold the vanco until after the trough came back. He's worked elsewhere, I work with him in ICU, but this was a Med-Surg pt that I was handing over after 4 hours, after having floated.

    Anyways he said that he always waits to start the vanco until after the trough is back, that it was protocol where he worked before. I discussed it with other co-workers and traditionally where I work we start up the vanco immediately, leaving the trough and peak for pharmacy and the doc to evaluate. I discussed it in the morning with yet another co-worker and we all agreed that perhaps we need clarification on this.

    What is the policy where you work? Any opinions? We are going to bring up this question with pharmacy and our manager.
    We do peak and trough on the 3rd dose. Trough is done 1/2 hour before the dose and peak 2 hours after it is done infusing. If there is something off about the trough, the lab will call and the dose will be stopped. We don't hold the dose for the results though.
  9. by   Tweety
    I would think by definition you don't hold the dose, because you're doing peaks and troughs which are done right before and just after.

    Currently we are doing troughs only just prior to the third dose and hold the dose until the troughs are back. Then we have individual paramaters as to whether to give the dose or not.
  10. by   GardenDove
    I think our hospital needs to try to have a policy. Currently it seems that it's haphazard depending on the doc. It's not often that the vanco trough happens to land on a dose that I'm giving, so honestly I don't deal with it often, and was just going by what has been traditionally done. In this case, it wasn't a pharmacy order, but a doctor one, and he specifically wanted a peak and trough done on that particular dose, with no further instructions.
  11. by   GardenDove
    Yes Tweety, that was my take on it too, that they wanted both peak and trough on that dose.
  12. by   GardenDove
    Just an update, I spoke with my manager and with pharmacy. My manager said that I hadn't done anything incorrectly and refered it to pharmacy. Pharmacy told me that yes, my co-worker had spoken to him about this, and that he had informed him the policy. He had also asked my co-worker for the name of the nurse who had hung the vanco. Interesting that my co-worker had pretended to not remember, I know that he knew very well because he is often my partner in ICU.

    I'm now going to have to have a little chat with him regarding his lack of diplomacy in blasting me in report in front of 6 other people regarding this. He basically confronted me big time with his usual arrogent "That's not the way I've done it where I worked before". I actually really enjoy working with him, but he does have a cocky, know it all manner that could use some curtailing.
  13. by   CRNI-ICU20
    At the hosp. where I now work, we have infectious disease docs who manage the peak and troughs of the patients on vanco, etc. I agree, it would be good to have an evaluation of what should be standardized....because without some sort of standard, some patients might end up getting that next dose with their vanco levels too high and then on to dialysis we go!
    If you have an infectious disease specialist or renal doctor on board, suggest to them that they write specific parameters....better yet....incorporate the help of the pharmacist as well....and then get it all on a written protocol/policy.....
    when everyone gets on the same page, it makes life easier for the care to be delivered, and for the ones designing the care....
    We have several protocols at our hospital that makes initiaton of care very easy and precise....
    Pneumonia protocol
    Sepsis protocol
    Bowel Function protocol
    just to name a few....each one has real specific guidelines that were decided on via evidence based medicine, and geared for our population of patients....
    We had input from the intensivists, the ID group, the Renal docs, and from the internal medicine groups....
    It sounds complicated in the beginning....but well worth the struggle....
    now we just follow the guidelines....and no one argues over this stuff....
    saves time and energy, in the end.
  14. by   Agnus
    We do peak and trough on the 3rd dose. Trough is done 1/2 hour before the dose and peak 2 hours after it is done infusing. We don't hold the dose for the results.
    We also do random draws.
    Additionally, we are directed to give the Vanco on time as scheduled. I have yet had to hold a Vanco because the trough was too high. If lab were to call with a critical high trough I would stop it and CAll pharmacy.

    Vanco is one of those drugs where pharmacy insist there be no deviation from giving it at the scheduled time. They insist if we are not able to give it well withing 30 minutes (at most)of the time it is scheduled we must call them.

    The policy for this should be written by pharmacy.

    A critical high trough to me would suggest a previous med error. I just have not run across this.
    Last edit by Agnus on Mar 4, '07

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