Cipro and ITP. What would you do?

[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.

[Altra, BSN, RN]

I would have given the Cipro.

This patient was/is most likely circling the drain.

What exactly is your director asking to discuss with you?

[tmd76]

It is not so much the director wanting to discuss it, but that doctor called down to the ER 5 times yesterday after the patient ended up in ICU..just harrassing the charge nurse and saying "you guys better get on this". He wants me in trouble.

[buddiage]

yeah.... not seeing the connection on what you did that would've caused the pt getting coded a few hours later.

He has a history of ITP, so this is chronic for him then?

Your pulmonologist is trying to hide behind a distractor, and that would be YOU, and he is a small man for looking to get at you for this ("ahhh, i got her now!!!"). What a coward.

If you need an affirmation, I'm giving it to you- you did everything right.

Secondly- there are times when people have enough of the deck stacked against them to make them lose. Your pt had enough stacked against him to bring him to the situation the PCU had to deal with.

[tmd76]

Yeah, this doctor is very well known for doing this. He does not like me anyways because we had a fallout because I didn't do something that he forgot to write orders for. He wrote orders on a patient 1 hr after they were discharged home from the ER. He was stupid enough to time his order accurately and put it in the already put away chart, then went all the way through administration to try to get me in trouble. He was told he was wron (of course) because how could I carry out orders that were never written. He also calls the ER and yells at the secretaries because he has to push too many buttons to get through to the ER. If the docs liked him, maybe he would have a direct line to them (haha). He is just a jerk, and does not play well with others. I see this as a way to try to get me in troube for real.

[tryingtohaveitall]

Yeah, this doctor is very well known for doing this. He does not like me anyways because we had a fallout because I didn't do something that he forgot to write orders for. He wrote orders on a patient 1 hr after they were discharged home from the ER. He was stupid enough to time his order accurately and put it in the already put away chart, then went all the way through administration to try to get me in trouble. He was told he was wron (of course) because how could I carry out orders that were never written. He also calls the ER and yells at the secretaries because he has to push too many buttons to get through to the ER. If the docs liked him, maybe he would have a direct line to them (haha). He is just a jerk, and does not play well with others. I see this as a way to try to get me in troube for real.

There's such a ridiculously loose association between the Cipro and the code that I can't believe the dr is even trying to make an issue of this. You did what you were supposed to, no way there's a correlation. Try not to let him get to you and just keep doing what you know you should.

[tmd76]

Update: I emailed my director, he had already gotten all the info from the doctor and my charge nurse. He said I did nothing wrong but he still wants to talk to me about it face to face, so he asked that I come see him when I work again. He said he appreciated that I started the floor orders, though I didn't have to. Although, I do regret starting the floor orders, because then I would not have been the one to give the Cipro. Then the doctor would be blaming some other poor soul.

[adria37]

If their kidney function was bad why in the world would they give Cipro in the first place. ITP can be worsened by infection (IE will be). I would expect a doctor know this about ITP.

http://www.emedicine.com/emerg/TOPIC282.HTM

[tmd76]

Thank you so much for that article. I just read over it, and realized that it says that you cannot give quinine to a patient with ITP. I do think it was the infection that caused this, but I wonder if that doctor is not confused. He is thinking quinolones (cipro) cannot be given, and he probably means quinine. I am going to print this out and take it to work when I go back. I think the Cipro was given because they were weighing risks and benefits and thought the benefits were greater than the risks, since he was septic. I forgot to mention his WBC count was 26. I am sure the sepsis is the culprit though.

[adria37]

An allergic response can also cause ITP to develop and worsen but based on his low plt count prior to Cipro IV I would still lay it at the sepsis unless his reaction to Tequin was ITP.

He is on dialysis was the previous reaction diabetic related? Tequin was removed from the market based on it's effect on glucose. I would do my research so you do not get blind sided in the meeting.

It usually does not bode well for the nurse to be called to a meeting with a doctor and director. I would have my rationals for what you did. I do not think he was confused about quinine at all and would not even go that approach, IMHO

[Altra, BSN, RN]

Thank you so much for that article. I just read over it, and realized that it says that you cannot give quinine to a patient with ITP. I do think it was the infection that caused this, but I wonder if that doctor is not confused. He is thinking quinolones (cipro) cannot be given, and he probably means quinine. I am going to print this out and take it to work when I go back.

Whoa - enough. If he's that convinced that the Cipro was harmful to the patient then he should be pursuing this with the MD who wrote the order. You are allowing him to make this about you when it is not about you at all. You're being railroaded into defending another provider's decision. You're also setting yourself up to have to answer the question, did you take into account all of this subsequently gathered info re: quinolones and ITP before you administered the Cipro? You don't want to go down that path.

If I were your director, that is what I would be discussing with you tomorrow.

Let us know how this turns out.

[tmd76]

I am not meeting with the doctor and director.....just the director. My director has already emailed me and told me not to worry, that I did nothing wrong. He just wants to discuss this with me (I think because I was really upset when I emailed him this morning) The patient was not diabetic, so I am not sure why he had ITP, but he told me during my initial assessment when I asked him about all his bruises, that he had ITP (chronic).