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.
Specializes in ED, Tele, Med/surg, Psych, correctional.
Wait a minute..because I think I'm missing something here. Aside from the whole Cipro thing...is anyone else wondering why a dialysis patient was getting IV contrast injection? Isn't this raising any red flags? I've seen patients with renal insuffiency mistakenly get IV contrast and then end up on dialysis as a result of this blowing out what remaining kidney function is left. Doesn't anyone think that this could have contributed to the patient's declining function? It would appear that the patient coded after the CT scan if I am reading correctly.
Aside from that...a septic patient with a WBC count of 26 in resp distress on arrival with multiple co-existing medical problems is a sick person to begin with.
Dialysis patients CAN get IV contrast as well as PO as long as its cleared by their nephrologist. It depends on the reason for the CT: if it is to rule out a AAA (with high probability or known AAA) then yes, judicious use of contrast is okay. Also - must consider if possible to dialyze off the dye immediately after CT. Then...must also consider whether pt has residual function or not and how important that is to the particular pt as to fluid overload and other comorbidities.
Dialysis patients CAN get IV contrast as well as PO as long as its cleared by their nephrologist. It depends on the reason for the CT: if it is to rule out a AAA (with high probability or known AAA) then yes, judicious use of contrast is okay. Also - must consider if possible to dialyze off the dye immediately after CT. Then...must also consider whether pt has residual function or not and how important that is to the particular pt as to fluid overload and other comorbidities.
This has been my experience - there is actually a little more leeway to utilize contrast with patients already on dialysis than patients whose precarious renal function is being managed without dialysis.
Specializes in ED, Tele, Med/surg, Psych, correctional.
traumasrus and altra:
my reaction to the IV contrast was in response to this particular case being discussed. There is no question that in cases of critical emergencies such as ruling out of AAA, arrangements can be made to perform this study. However, in this particular case I am assuming that the patient was having a CT of the chest to rule out a PE. This isn't specifically stated but I assume this based on the fact that the patient was in resp distress and being admitted with a working diagnosis of pneumonia and CT of chest ordered. I am guessing however. I would have to believe (hopefully) that if they believed this patient to have a AAA they would not have transferred to the PCU until results obtained as surgical intervention may be warranted. My issue with contrast in this particular case is that the benefit should outweight the risk with a dialysis patient. To rule out PE in my hospital...a nuclear VQ scan can be performed in place of a CT with contrast for those with kidney dysfunction or contrast allergies. There is no reason to put a patient at risk when there are alternative studies available.
jenfromjersey
44 Posts
Wait a minute..because I think I'm missing something here. Aside from the whole Cipro thing...is anyone else wondering why a dialysis patient was getting IV contrast injection? Isn't this raising any red flags? I've seen patients with renal insuffiency mistakenly get IV contrast and then end up on dialysis as a result of this blowing out what remaining kidney function is left. Doesn't anyone think that this could have contributed to the patient's declining function? It would appear that the patient coded after the CT scan if I am reading correctly.
Aside from that...a septic patient with a WBC count of 26 in resp distress on arrival with multiple co-existing medical problems is a sick person to begin with.