Antibiotic Situation

[StephRN08]

Today, I had a patient admitted with elevated LFT's, fever, and suspected gangrenous cholecystitis. She was ordered a STAT CT scan of the abd/pelvis and started on meropenem and vancomycin. Also, she needed transfused with 2 units of PRBC's for a hemoglobin of 5.9. Her venous access was TERRIBLE! She had one peripheral IV (20g in the right FA), and I managed to start another peripheral IV (24g in the left hand). Needless to say, the docs wanted her to have a PICC line placed. Her antibiotics were schedule for 1pm, so I called radiology to find out when they could take her and was told it would be before 3pm. The PRBC's were transfusing throughout the day, so that occupied one line. Around 1pm, she wanted something for pain, so I went to give her something and she complained that her other IV was painful when I flushed. I removed the IV and then re-scheduled the antibiotics for 7a-3p-11p (was originally 5a-1p-9p). I did this so that her IV antibiotics would not be late and would not be administered too close together. She went down for her PICC line around 2:30pm and was still in radiology when I gave report to the next shift. The RN and her orientee both gave me a strange look when I told them about this scenario. I was asked why I didn't give the antibiotics through the other IV and explained that I did not feel comfortable giving vancomycin through a painful 24g IV in the hand. I also reinforced that she still had PRBC's infusing. I still don't think my rationale was understood.

My question is... does it seem like I did the right thing? I know antibiotics are extremely important, but I did not want to create any other problems - like a vancomycin extravasation! Any thoughts on my actions? What would you have done?

[BellaInBlueScrubsRN]

So did she not get any antibiotics on admit?

No, I wouldn't given anything through a painful IV site... especially if I thought it wasn't working. It would need to be taken out immediately. Thinking back, with the diagnosis and only one IV access, I might have given the vanc first since it goes in over an hour and PRBCs take a few hours.

[StephRN08]

She was admitted last evening, so she received 9pm and 5am doses of both antibiotics. She was very symptomatic with her hemoglobin and had an extensive cardiac history. I started the PRBC's at 8am.

[OttawaRPN]

Why didn't you just insert another PIV to run the Abx?

[StephRN08]

This lady had terrible veins! We had IV team look and they couldn't find anything else.

[Daliadreamer]

I think you did the right thing with what you had to deal with. I personally would give the blood priority, obviously, because her Hg was that low. You could have given her the antiobiotics in between the blood (blood, abx, blood, abx) but it sounded like it was chaos with this patient and I'm sure you had other patient's too. You did what you could.

[brownbook]

I agree with daliadreamer. You did the best you could do. Easy to Monday morning quarterback the whole situation. You SHOULD haves may come by the bushel full. You did fine, it was a difficult situation. I hate on coming nurses questioning why such and such happened or wasn't done!!!!!!!!

[Been there,done that, ASN, RN]

A nurse Cannot administer any medications, transfusions, medications without a viable line. It is your call to decide that a line needs to be placed to safely administer prescribed treatment. It can be painful to wait for the line to be placed, however, there was nothing else you could do.

[kmmRN,BSN]

I would have done the exact same thing. I don't know why any nurse would try to give a medication through an IV site that has gone bad (which is what this clearly sounds like) just to get the medication passed. And, It wasn't like you didn't take care of the problem, as you had already rescheduled the antibiotics and the patient was in the process of getting a PICC line. You did what you could with the situation. Especially if the patient was symptomatic from the low hemoglobin, giving the blood would have been my priority too.

It almost sounds as if this nurse was upset that you were "passing on" some of your work to her/him. Our manager always stresses to us that there is only so much you can get completed in your shift, and there will be times that you will have to pass on some of the work to the next shift, as there are bound to be times when others will have to pass on some work to you. Yes, it can add a little stress, however, this is what teamwork is about, and if you can't be a team player, then I don't know how you can survive in nursing.

I think you did exactly what you should have done in this situation. And shame on that other nurse for questioning you about why you didn't give the medication through a bad IV

[SharonH, RN]

I agree with the others, your actions sound appropriate. Really what else could you have done, it would have been silly to start another PIV if she was on her way down to have a PICC placed! Don't give it another thought.

[lkwashington]

I agree with the others. I feel you done the correct intervention. Air, Breathing, and Circulation. You provided CIRCULATION to the patient. Good job!!!

[blamejoe]

another point maybe to be had:

Even if that 24g IV in the hand was not painful, I never give anything simultanously to blood. If the person is on TPN and already has a dual or triple lumen access, too bad. I think blood is the important compenent to their treatment, and if you're given other fluids and something goes wrong, as question as to why occurs where there should be interfering factors at all. Antibiotics are pretty important, but still not as important as blood. Especially since she had received doses already, but even if she didn't; with an Hgb so low, additional fluids means additional dilution of the RBCs.

I think you did exactly the right thing. Our colleagues' job is partially to question us, and they may even disagree, but judging should almost always default to, "that nurse did what they thought was necessary using their clinical judgment" unless apparent factors exist.