I am currently in a 14 week internship for new grads so I'm with a preceptor every shift.
Saturday when I worked I got a little behind and had two IV antibiotics due for one patient at the end of the day, Zosyn to run over four hours and Vancomycin over one hour. It had been a busy shift, a long day, and it was only week four of my first job as an RN (week 3 on the floor).
With that being said, I was a little frazzled and didn't check for compatibility but instead said something to my preceptor about running the Vanc first and then the Zosyn, even though the Zosyn had been due first. She said, "no, I would run the Zosyn first, it can be run in 30 minutes. Just run it at 200." I said "is it okay to do that?" And she indicated that it was.
That didn't really set off alarm bells because someone had just told me that the reason we run Zosyn so slowly is because the longer it is in the body the longer it works but that it can be run faster.
Fast forward to Sunday when I worked and I had a patient that was going to d/c within 1-2 hours but had Zosyn due. I mentioned something in the room in front of the patient/family and my (different) preceptor that the patient had a four-hour antibiotic due but that I could run it as fast as 30 minutes so they could leave (not my exact wording but the gist of what I said). My preceptor said "oh no, we can't do that!"
We didn't say anything else about it until we left the room and I explained why I had said that. She said that running it faster can cause toxicities/renal failure and that you should never run it at 200ml/hr.
I do want to say that I don't believe it is best practice to infuse medication at a rate different than the prescribed rate, and it is not something I plan on making part of my practice. Now that I think about it, outside of the moment, it is a medication error.
However, I researched it some later and from what I can tell, it appears that the manufacturer intended for it to be run over 30 minutes, or 200ml/hr.
So my question is, has anyone ever seen Zosyn (3.8g in 100ml) prescribed to run over 30 minutes?
Also, just out of curiousity, what is everyone's take on what the first preceptor told me - was she way off base or is this something you have done/seen done?
As mentioned by others, Zosyn is given over 30 minutes all the time in the ED. It's be a little while since I worked on a floor, but I believe, at my facility, Zosyn was given over 3 hrs on the floor. It was printed on the label sent up with the med from pharmacy "infuse over XX minutes." I'm not sure exactly how the policy is written, but I would want the pharmacy's blessing before going with a different infuse time, not just my preceptors blessing.
Giving Zosyn over 30 minutes is still the FDA labelled infusion duration, and there's no risk in doing so, and we don't use 4 hour infusions for renal impairment but rather adjust the dose. For certain infection sources there is some evidence that a 4 hour infusion can slightly improve outcomes. This is for infusions after the loading dose which is why it's typically given over 30 minutes in the ED since that's typically the first dose.
Specializes in L&D, Cardiac/Renal, Palliative Care.
Thanks everyone for your replies! Obviously I do not intend to make adjusting infusion times without a physician's order a part of my practice. I just was curious if anyone else had encountered this.
I think it threw me even more because my second preceptor was one of my former professors in nursing school, so I thought maybe I had done something way off base. It sounds like though, from feedback here and talking to others, that strangely, it is kind of common practice to adjust infusion time...
Specializes in orthopedic/trauma, Informatics, diabetes.
Big bone of contention about the Vanc/Zosyn issue. We have IV nurse experts. One is a legal expert nurse. even though pharmacy tells us that the two are compatible, IV nurse said, if there is ever a reaction-which one caused it? Point taken. He advised getting the meds retimed. Run the Vanc first and then Zosyn. Almost all of ours are 4 hour infusions. WE cannot decide to change that. I either get another IV placed or retime them via pharmacy so they can time trough draws.
I have see people hang cefipeme with Vanc thinking it is Zosyn and compatible (both are 4 hours). We are having a big education push about reading more carefully administration directions and always checking compatibility AND checking with pharmacy. Also never give something that you do not know about. take 5 min to learn why you are giving it, what is it for and what side effects it might have.
Specializes in Surgical, Home Infusions, HVU, PCU, Neuro.
Zosyn and vanco are compatible at y site if the vanco is reconstituted in NS and the mg/ml is between 2 and 5. So if 1 gram vanco is ordered in 250 NS your concentration is 4mg/ml, 1 gram in 500 is 2mg/ml. These are compatible with zosyn 3.75. We run zosyn as a primary d/t the increased infusion time. If unable to and you have the choice of Vanco or zosyn Vanco needs to run first. Vanco must maintain a therapeutic blood concentration for effective treatment, which are time by dose number and a trough draw usually before the 4th dose. Most hospitals have pharmacy dose the vanco and use the trough to determine if the amount is too little, too much, or just right. If your facitily has Micromedex there is a comparability chk on it to determine y site compatibility. The patients renal functuon should also be checked while a patient is on it because of the nephrotoxixity. If all else fails or peace of mind needed call the pharmacist. Running zosyn at 200 for a 30 min infusion may be against hospital policy, make sure you check that and ask the DR if need be because changing the time infused and/or rate is a med error. Hope this helps!
I just finished a new grad nurse residency and have to say that one of the hardest things to deal with is working with different preceptors who do things different ways. This situation I think it a little bit more nuanced, but in general I think a good preceptor should see grey areas within in nursing and be able to say "This is how and why I do my practice this way, someone else may do it differently, you need to decide for yourself what you want to do."
In this situation, as with all med questions, I agree with others in calling pharmacy. This also covers your own a** because when you scan the med in you can write your whole little comment in about why your running it in faster and then put "per so and so pharmacist okay to do so" lol
Specializes in Adult and Pediatric Vascular Access, Paramedic.
You could always ask the doctor or pharmacy to put the meds at different times so they do not overlap.
Also another idea would be to put a second IV in, if the patient doesn't have difficult access. The only downside is if they have an allergic reaction and both are running simultaneously you wont' know which one is causing it, but since he has been on them already chances are low of this happening. Consult with the pharmacist first of course and make sure it is ok to run them both at the same time to make sure you wont' overload their renal system.
Pharmacy is your friend, consult them. I know the instinct is to just ask your preceptor, but use your other resources.
I agree with this. When you're new, it's easy to question your own judgment and just go along with the preceptor's advice, but preceptors can make mistakes. And I promise you that this is a lesson you'll never forget. :) The pharmacists don't mind us calling them; they usually love to teach and don't often get the chance in the hospital setting.
AnnieNP, MSN, NP
540 Posts
Yes to this!