Okay, so I had a situation at work theother night that I would love some feedback on. I had a very sickleuk on day 28 of HAM. He was neutropenic, and had had a fever acouple of days before. I work the PM shift, and when I came in hislabs from that morning showed a hemoglobin of 7.3 and platelets of 9.We transfuse under 8 and 10 of hgb and platelets respectively. He hadgotten platelets that day and bumped to 13, but the nurse was unableto get in the two units of ordered blood b/c of his many antibioticsand a trip to CT. He only had a single lumen mediport, generalized+1-2 edema, and was sporting a rash probably due to cefepime(on top of a clearing cytarabine rash). The AM shiftmade several attempts to get in a peripheral but was unable,phlebotomy couldn't even get a flash. So I arrive, and plan to givethe first unit after his Vanc. At 2200 the tech helps him to thebathroom and we notice the chucks under his bum is saturated withblood. He has a small tunneling wound next to his anus, an externalhemorrhoid, and horrible diarrhea r/t mucoscitis. So I bagged theVanc and got his first unit of blood up, followed by a unit ofplatelets. We even called rapid response to see if THEY could get aperipheral on him, alas, no dice. By the time the blood and platelets were in, it was too late for the Vanc, so I gave the rest of the antibiotics ontime followed by his second unit of PRBCs. The resident and charge both agreedwith my decision to hold the Vanc, but I caught a little bit of hellfor it from his nurse the next day. I'm a fairly new nurse (1+ yearsof experience), and while I'm still standing by my decision, whatwould you have done? Normally antibiotics are my first priority, and he ended up remaining hemodynamically stable.We didn't have any more incidents of large bleeds, but he could haveeasily gone the other way. I've had colleagues run in 5 or so units on a bleeding pt overnight. Has anyone ever given blood aroundantibiotics? I know we have six hours to get the blood in, but thetubing only lasts four. I've never stopped blood mid-infusion before,how do vitals work if I had tried that? We actually have this problemon a fairly regular basis, so any suggestions would be nice. Thanks
PS- It dawned on me later that I couldhave asked the resident to start an IV via ultrasound, but she didn'tthink of it either. Plus our docs aren't too comfortable with theprocess. Thinking I may get trained, but I'm a pretty crappy stick...