Vanco Administration Question Please!

  1. 0 Hey Everyone,
    I recently started a job in a clinic and only have been a RN for almost a year and had a question. I have not worked in the hospital and only start IV's in the clinic a few times... but today we had a patient that was getting vanco IV. In the past the provider made us give the vanco via gravity, so today I went and borrowed a pump from a different department because I read that you HAVE to give vanco via infusion pump for patient safety. I also talked to another nurse that I borrowed the pump from about certain standards of giving vanco she said we usually have a primary line going and piggy back the vanco 1 gram in 250mL of normal saline and infuse at 167mL hour (1.5 hours).

    So I got the pump ready and the provider ordering the Vanco was mad I got the pump and said "you should just be able to look at it and know how fast it is going, if you have any problems with that pump don't ask me for help because I do not use them." He also wanted me to mixed that 1 gram of vanco in only 50ml normal saline? And I had a protocol for our facility that said it has to be mixed in 250mL of normal saline. I told the provider I did not feel comfortable giving the vanco without the pump because "i cannot judge how fast it is going." and that the standard was suppose to be 250 mL. He said okay whatever mix it in 250mL of saline. So the dr had me start the primary line by gravity and once I got the vanco mixed he told me to stop the primary infusion and just infuse the 1 gram vanco(in 250mL) over at least 1 hour. After 1 hour it was not infused all the way because the pump was set at 167mL an hour he said please disconnect from pump and I want the rest ran through gravity and he set drip factor (which was wide open because he said it was not going fast enough)

    1st question- was it wrong telling him I wanted to use pump because I did not feel comfortable, it felt safer for me and the patient

    2nd- can you give vanco just through a primary line without piggy backing? (because he told me to stop it and just do the vanco)

    This just made me feel very uncomfortable today and need some advice because I am not around this stuff everyday. I am also looking for another job because I believe I should not be treated this way when I am trying to keep my patient safe and my license. I also documented everything he told me to do step by step, to cover me. Please be kind
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  3. Visit  suzi0612} profile page

    About suzi0612

    Joined Aug '11; Posts: 17; Likes: 8.

    14 Comments so far...

  4. Visit  NicuGal} profile page
    1
    Are you at a hospital afflilated clinic? They should have med guidelines to use. In our hospital and clinics we always use pumps, nothing goes in by gravity anymore. We do give Vanco without a primary on our unit and on peds. Do you have a supervisor you can talk to about this?
    piya hanni likes this.
  5. Visit  suzi0612} profile page
    0
    I actually used a printed out guideline from the clinic beside us that I used the pump. I told my manager she told me to document everything he told me to do ... I was just so upset because I was trying to follow guidelines for me and the pt and ge made me feel bad about... I'm currently trying to find a new job... I am not going to do things that the dr tells me that makes me uncomfortable ... Not risking my license!
  6. Visit  suzi0612} profile page
    0
    I'm at a clinic ... forgot to mention that!
  7. Visit  Esme12} profile page
    0
    first, i am glad you are looking for another job. they are supporting practices that are not safe and i can't believe the "provider" was encouraging the use of the vanco in contradiction to manufacturing guidelines and all recommended administration guidelines.

    second, i am concerned, have you given this drug in the past without looking it up? it is never a good practice to give meds without looking them up first. i have been a nurse for a long time and i still look up every drug i am unfamiliar with before i give it.....i trust no one but myself. i also carry malpractice insurance, which i recommend everyone to carry, to cover me......it is cheap and will cover legal expenses and provide a lawyer even to protect your license with the board if anything ever happens for any reason. you need to get malpractice insurance if you don't have it......it's the smart thing to do. no matter how much you documented what the provider said.....you are the one responsible. if the "provider" wanted to run it by gravity i would have suggested to the provider to disconnect it himself. i would not have opened the pump and i would have allowed it to to finish by pump.

    vanco given too rapidly can have serious side effects.

    warnings
    rapid
    bolus administration (e.g., over several minutes) may be associated with exaggerated hypotension, including shock, and, rarely, cardiac arrest. vancomycin should be administered over a period of not less than 60 minutes to avoid rapid-infusion-related reactions. stopping the infusion usually results in prompt cessation of these reactions.

    ototoxicity has occurred in patients receiving vancomycin. it may be transient or permanent. it has been reported mostly in patients who have been given excessive doses, who have an underlying hearing loss, or who are receiving concomitant therapy with another ototoxic agent, such as an aminoglycoside. vancomycin should be used with caution in patients with renal insufficiency because the risk of toxicity is appreciably increased by high, prolonged blood concentrations

    adverse reactions

    infusion-related events during or soon after rapid infusion of vancomycin, patients may develop anaphylactoid reactions, including hypotension, wheezing, dyspnea, urticaria, or pruritus "red man" syndrome. rapid infusion may also cause flushing of the upper body (“red neck”) or pain and muscle spasm of the chest and back. these reactions usually resolve within 20 minutes but may persist for several hours. such events are infrequent if vancomycin is given by a slow infusion over 60 minutes. in studies of normal volunteers, infusion-related events did not occur when vancomycin was administered at a rate of 10 mg/min or less.

    miscellaneous

    infrequently, patients have been reported to have had anaphylaxis, drug fever, nausea, chills, eosinophilia, rashes including exfoliative dermatitis, stevens-johnson syndrome, and vasculitis in association with administration of vancomycin.
    chemical peritonitis has been reported following intraperitoneal administration of vancomycin
    vancomycin hydrochloride official fda information, side effects and uses. .

    red man syndrome

    also known as.......erythroderma

    vancomycin must be administered in a dilute solution slowly, over at least 60 minutes (maximum rate of 10 mg/minute for doses >500 mg).this is due to the high incidence of pain and thrombophlebitis and to avoid an infusion reaction known as the red man syndrome or red neck syndrome. this syndrome, usually appearing within 4–10 minutes after the commencement or soon after the completion of an infusion, is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. these findings are due to non-specific mast cell degranulation and are not an ige-mediated allergic reaction. less frequently, hypotension and angioedema may also occur. symptoms may be treated or prevented with antihistamines, including diphenhydramine, and are less likely to occur with slow infusion.

    red man syndrome

    so now to your question. you are responsible for what you do. saying "because he", the "provider", doctor,pa,or np......will not absolve you from liability. you are responsible for what you do. i have, on many occasions over the years, suggested to the md that if the wanted something, given i certain way, they are free to give it themselves.

    i once had a md screaming (well, i've had md's scream many times, for many things, over the years) at me to continue to administer an antibiotic to a 80lb child (38kg) that was dosed by pharmacy for a 80kg (170lb)adult and i refused. he was going to have me fired, report me to the board and have my license revoked, arrested (just kidding) if i didn't do as he ordered and commanded. i still refused, i saved the child from liver failure/toxicity and got the order changed by the chief of the service.

    what kind of "provider" is this? what is their role in the clinic?

    using the pump is the safest administration method in this day and age, although it can be piggy backed to gravity, slowly (remember those counting the drops calculations nursing school?) but it has a high probability of infusing too fast. why does the provider infuse in the clinic? why do the not send then to an infusion room in the hospital next door? is this just for revenue to the office so they are willing to risk patients for profit?

    vanco is best piggy backed into a main line. one if it isn't "piggy backed" it's not longer a "piggy back" right?it becomes the main line. second if the patient has a reaction, and hypotension is common, you already have your flush/bolous line ready. vanco is very caustic to the veins so the better diluted the better.

    do you have a nurse manager that is a nurse there that over sees the nurse practice/safety issues? go to them with your concerns.

    lastly.....good luck on your job search. i am sure there will be a better fit for you out there......just don't quit until you have another position. :d
    Last edit by Esme12 on Feb 17, '12
  8. Visit  Hoozdo} profile page
    0
    1) No
    2) Yes

    It has always been policy, wherever I have worked, to infuse Vanco on a pump. It is always in a 250 mL bag, max infusion rate is 167.5 mL/hour. It can be infused on a primary line.

    Personally, I would have infused it on a pump also.
  9. Visit  morte} profile page
    0
    usually policy to use pump, of course, technically can be done without. BUT!, what is the policy at this clinic? if it says run it on a pump, than on a pump it must be, or you will be toast if anything goes wrong. I am thinking "time is money" and this provider wants the trough put for patients to be as quick as possible.
  10. Visit  suzi0612} profile page
    0
    Thanks for everyones comments! The provider just made me feel so bad about it and that I was dumb.. Glad I used the pump ... Made me feel comfortable !
  11. Visit  MN-Nurse} profile page
    1
    Man am I glad to work at a facility where the MDs prescribe, the pharmacists verify, and the nurses administer.
    netglow likes this.
  12. Visit  Altra} profile page
    0
    I'm glad to see that you used appropriate resources in this situation: your facility's written med administration guidelines/policies are your Bible.

    Be confident in them, and do not allow a provider to "make you feel bad". People can be angry for whatever reason -- it is NOT necessarily a reflection on you.

    What was the stick up this provider's butt, anyway? The time required for IV Vanco administration? Now s/he knows better -- order IV Vanco -- the patient is going to be taking up the exam room for 1.5 hours.
  13. Visit  SappyRN} profile page
    1
    I have seen "red mans" in children with a slow infusion. It is something you will never forget. Find out what your clinic policy is and discuss the situation with your immediate supervisor so next time you have some back up. When it happens again, and it likely will, simply explain that performing this is against policy and you cannot do it...if the doctor chooses to do it himself, document everything in a diplomatic non-accusatory manner. You can then control your your situation better and continue to provide optimal patient care so the patient gets monitored for adverse reactions. Notify your supervisor if the breech of clinic policy by the physician or file an incident report for patient safety. You cant go wrong following policy, being professional, and providing good patient care.
    Esme12 likes this.
  14. Visit  joe17} profile page
    0
    1st question- was it wrong telling him i wanted to use pump because i did not feel comfortable, it felt safer for me and the patient
    no your not,you have to used your judgement to safely administer the medication.you are absolutely right in telling him the best way of administering vancomycin.if it is a small dose (250mg)then yeah i would probably just calculate it without a pump and if this is a regular meds(patient has been taking it for few days)the fact that this is the ist dose/time the patient recieving the meds.


    2nd- can you give vanco just through a primary line without piggy backing? (because he told me to stop it and just do the vanco)

    yes you can give it as a primary iv without piggy back.in fact and in practice 1000mg of vanco can also be mix in 50ml but give it slowly(1-1.5 hrs) or the safest is 250 ml in an hour...just like any other meds given rapidly can cause harm as previously mentioned by others here.

    you did absolutely well..good for you.......... you stand for what is right for you and for your patient.
  15. Visit  Isabelle49} profile page
    0
    You did a great job being an advocate for patient safety. I have once had to give Vanco in the home and I told the agency that I would not do it if there was no pump available, or elastomeric system.


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