Cipro and ITP

[tmd76]

I have been a nurse for going on 3 years now, I have in my 10th month of ER nursing. I have had a recent fall out with a pulmonologist at the hospital I am at, and tonight I had another issue with him. I had a patient come in today with history of ITP and ESRD (on dialysis), having trouble breathing. Patient was in tripod position when I entered the room. I immediately called RT, started IV, collected blood samples, etc..then the ER doctor came to see him. He ended up with diagnosis of Pneumonia, and I sent him to the PCU on a NRB at 15 LPM. Patient's vitals were stable. The doctor wrote Cipro on the admit orders, patient was allergic to Tequin (unknown reaction). I went ahead and gave the Cipro (IVPB over one hour) before I sent him to PCU. Patient went to PCU about 30 min after Cipro was finished. Patient was stable. I got a call about 3 hrs later that the patient had coded and they needed to know what family had been in the ER earlier. The pulmonologist later called and told my charge nurse "I saw the chart, I know who the nurse was. She gave the patient Cipro, and now he has ITP". One: the patient had no reaction in the ER, shouldn't he have had a reaction long before 2 1/2-3 hrs later, and Two: The patient already had history of ITP. I spoke to the CT tech and she said the patient crashed in CT during a CT of the chest with contrast. The patient's BUN and creatinine were through the roof. I think he should not have had contrast. She said she asked the attending and the radiologist and they both approved the contrast. Does anyone have any opinion or suggestions? I have to address this issue with my director tomorrow.

[SuesquatchRN, BSN, RN]

Well, Tequin and Cipro are closely related. I am assuming that the prescribing physician was aware of both and considered the Cipro necessary.

Why would this be your fault?

[tmd76]

That is what I am trying to find out. I don't feel like this could be my fault. I am trying to research and see if there is any relationship between Cipro and ITP. I think this guy was a code waiting to happen. All the other nurses I work with agree with me, but the ER physician that was taking care of the patient was already gone for the night. I am anxious to see what his opinion will be. He is a very intelligent and trustworthy physician, I have full confidence in him. I also know he was aware the patient had ITP. Apparently the pulmonologist was somehow not aware. I just hope this is not some personal vendetta this doctor has with me....

[SuesquatchRN, BSN, RN]

http://www.pdsa.org/assets/e_news/2001/nov-5.htm

I can't see this as your fault.

[iluvivt, BSN, RN]

This does not seem like it is your fault. I am assuming you are talking about idiopathic thrombocytopenia purpura...right? By the the way they just call it TP now b/c they know what causes it now and have dropped the idiopathic. Good for you for finding out all you can so they do not railroad you as nurses often are. I find no contraindication or even a mention of a precaution with regards to the use of Cipro in this type of pt. I do know it should be administered over at least one hour to prevent crytaluria...but you said you did that!

Usually a reaction to abx will occur during the dose or shortly therafter and do not always occur on the first dose,sometimes second or third.

The most likely culprit is the contast media. I have been on tons and tons of codes at the CT scanner and very few for a drug reaction. Usually ,if caught early,a drug reaction can be easily taken care of with the usual Benadryl...H2 aganonist and some epi. I will look up the propensity for anaphylaxis to CT contrast media...b/c now I have to know.

[tmd76]

Thank you so much, I will give this reference to my director. Some of the other ER docs already told me that it is too far of a stretch to say that Cipro could be the cause. They said usually the Quinolones will cause a severe drop in BP, which did not happen. Otherwise, the reaction should have happened a lot sooner. I am going to keep researching though.

[traumaRUs, MSN, APRN]

I'm a nephrology APN and ALL dialysis pts are very ill. Sounds like he was fluid overloaded, in CHF (which is very common with our pts), got to the end of the line, which was cardiac arrest and that's the end of it.

Dialysis pts die from calcifications - so all die from some form of cardiac dz. Don't think you did anything at all wrong.

As to the contrast for CT, depends on the reason for the CT and the amt of residual renal function the pt has. You weigh and decide but it is sometimes okay to give contrast to an ESRD pt.

Take care and go to bed - you did nothing wrong...

[leslie :-D]

That is what I am trying to find out. I don't feel like this could be my fault. I am trying to research and see if there is any relationship between Cipro and ITP. I think this guy was a code waiting to happen. All the other nurses I work with agree with me, but the ER physician that was taking care of the patient was already gone for the night. I am anxious to see what his opinion will be. He is a very intelligent and trustworthy physician, I have full confidence in him. I also know he was aware the patient had ITP. Apparently the pulmonologist was somehow not aware. I just hope this is not some personal vendetta this doctor has with me....

when i checked out cipro under drug reference on medscape, it listed tp as a rare side effect.

yet, cipro can have serious interactions when someone has renal disease.

i'd try and stay clear of the pulmonologist, and take darned good notes when interacting with him (as we should with everybody).

let us know what happens.

best of everything to you.

leslie

[Flightline, BSN, RN]

This is getting way to deep. Did the nurse have an order for the Cipro? Was the pt allergic to Cipro? Was the correct dose given at the correct rate? That's all that matters from a nursing perspective. We are not MDs. The only way the original poster could mess this up is to walk around telling everyone: "I knew I shouldn't have given that Cipro; I just knew it. I bet I killed that patient."

Even if the Cipro and/or contrast shut down the kidneys, it wouldn't be the cause of a code in a few hours. I think TraumaRus put it very well.

[southernbeegirl, BSN, RN]

i dont get it. YOU didnt order the cipro, the doc did. how is he making this your fault? geez...good luck tomorrow!

[iluvivt, BSN, RN]

Thrombocytopenia can be a rare complication but is not necessarily a contraindication and it seems that in the case reports I just read it began to occur after several doses. I agree with everyone also....this is not your fault and do not let them make it your fault!!!