Antibiotic vs Blood

[AJpcvRN]

Hey all

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 orifice, 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...

[iluvivt, BSN, RN]

This seems to be a common occurrence in the Oncology population. They need all of this chemo,blood products,antiemetics,antibiotics,antifungals sedatives,electrolytes, blood draws,power injections for CT scan or injections for MRI plus more and they have a single lumen venous port...Great! and then the licensed practitioners ordering all the IV medications and blood products often forgot about the fact you only have one lumen to works with.

If this a commom problem for the nurses you need to be very proactive in securing an additional access. The patient sounds really ill and needed another central access optimally. If GFR OK you can request a dual lumen or triple lumen PICC on the contralateral side of the port. If you do not have a PICC team I noticed that the patient was down in radiology that day and could have had a PICC placed or a tunneled power line or other type of tunneled type CVC down in IR. We do this all the time..a pt comes in with a SL port and we place a PICC on the contralateral side for all the other things they need. If the LP forgets to order the nurses are on the phone and getting that order!

A PIV would have been good also as a bridge line until you can get something in better but apparently this was a problem and this indicates you need a PICC or other type of CVC. I am not a fan of US guided PIVs even though I do place them until we can get a PICC in. Studies show they have a high failure rate with about 50 percent failure within 24 hrs.

So in your situation I would have given the blood and platlets as you did and if I could would have given the antibiotics in between the next unit of blood. There is one more thing you could have done and we have done this as well if the LP did not want a PICC and a PIV was not an option. You could add a double T ext or dual lumen ext set to your huber needle but it MUST be added at the Y site of the non coring needle set (some have this configuration ) that way it the closest to the port or if you do not have this type and it is just a single tubing you can add the extension set to the end of that tubing. So you see you would still be giving the Blood seperate and attached to one end of the dual extension set and on the other end of the DL extension set you can give all the other meds. This is not considered mixing if you set it up properly as the flow rate in the SVC is so great as that is exactly where the tip of the catheter attached to the portal chamber is.

I would have also looked for a second PIV site after I gave the blood because often with the added volume the veins will be fuller and easier to get.... also try a BP cuff instead of tourniquet (place on arm upside down so bulb out of your way)...set at just below the pt's diastolic and clamp so pressure maintained..it works so well have some 2x2s ready and prepare to release. so pt does not get too many petchia b/c they will get some with that low of a plt count. Works very well as does heat packs. I would have used both if needed.

[DavidFR, BSN, MSN, RN]

Would probably have done as you did.

Was the patient taking orally? Could he have had a dose of oral vanc - not ideal but perhaps better than a missed dose. Could you have given the vanc straight after and reshcheduled his vanc doses - again, a late antibiotic not ideal but better than a missed one. Always easy to think of these things at a distance, but you needed to act quickly and I think you acted correctly.

Blood/haemodynamic status was your priority and I think you can very reasonably justify your actions. Sadly, some nurses in handover just love to get started on the "but you didn't do this or you didn't do that" rollercoaster. (S)he wasn't there and didn't have to make the on the spot decisions you did. It's always so easy to be wise with hindsight. You did well in a difficult situation. It takes time and courage to learn to defend yourself to nurses who've been qualified a hundred years, but you MUST gain confidence in defending your actions because sadly, there are some very insecure nurses around who criticise just to make themselves feel good. Don't take their sniping to to heart. You acted for the patient.

[mappers]

Would probably have done as you did.

Was the patient taking orally? Could he have had a dose of oral vanc - not ideal but perhaps better than a missed dose. Could you have given the vanc straight after and reshcheduled his vanc doses - again, a late antibiotic not ideal but better than a missed one. Always easy to think of these things at a distance, but you needed to act quickly and I think you acted correctly.

Vanc is very poorly absorbed orally. That's one reason they give it to C-diff patients because it acts in the gut without being absorbed into the blood stream.