Published Apr 6, 2014
Let's say you have a patient with a wound MRSA infection who also has low platelets(7). You have one hour left in your shift. Platelets are ready but if you hang them, antibiotic will be late. Pt only has one peripheral and is a difficult stick refusing further access attempts. Which do you hang? Two of my experienced coworkers disagree.
Based on the info you provided, I would run the platelets over 30 min (thats the rate the doctors order where I work) then hang the antibiotics. If the patient was septic, symptomatic, or very ill I might ask the MD if he wants the antibiotic first and let him know the patient is refusing a 2nd line since our hospital policy is that any patient receiving blood products has 2 lines.
I would hang the platelets first due to the count being 7,000 and any future invasive tests would need some platelets on board. Very often in my hospital, if a patient is a hard stick on the floor, they call the ER nurses or us ICU nurses to come give it a stick, otherwise the patient may need a central line. The antibiotic can wait, remembering your ABC should be able to allow you prioritize medications (i.e. patient having stridor post extubation with low blood pressure, you would give racemic epinephrine first before going for the levophed, neo or vasopressin). Hope this helps!
sistrmoon, BSN, RN
It's 6 am(actually it was closer to 6:20 by the time the call came the platelets are ready.) The antibiotic infusion is an hour. The platelets will be hung immediately before or after the antibiotic. No invasive procedures are planned. But basically it's going to bleed(pun intended) into the next shift. No active bleeding noted. Patient has not been getting a bump from transfusions.
I guess I'm having a hard time seeing how ABC comes into play here? Circulation?
The nurse with 30 years experience says antibiotic always takes precedence with active infection. The oncoming nurse(overwhelmed by morning transfusions) with 15 years experience said platelets should come first but relented a bit when finding out there was an active MRSA infection and it was a one hour antibiotic.
I would go with platelets first. An infection has been identified and treatment in place. Not addressing the platelets could lead to further medical complications. You're talking a 30 minute infusion, delaying an atb for that short amount of time will not cause any harm to the patient.
Here.I.Stand, BSN, RN
I would probably hang the platelets first, unless 1) the pt is showing signs of sepsis or otherwise symptomatic or 2) the antibiotic is frequent--say q 4 hrs or 6 hrs, thus giving you a narrower window of time than a q 24 hr dosing. Plus platelets can go in faster than Vanco, so you would be delaying the platelets longer by giving the Vanco first, than vice versa. Of course if there is any suspicion of bleeding I would give the platelets first.
You could let the provider know too, that the pt only has one line and refusing others, and ask if s/he has a preference which to give first. I'd also ask about getting the pt a dual lumen PICC if the pt is needing more access but is such a hard stick. Especially with something like Vanco which can be irritating in small veins.
dudette10, MSN, RN
Platelets first. At my hospital, you're allowed some wiggle room re: med times. It is possible that both can be given in rapid succession and the abx will not be late. If I was the off going nurse, I would start the platelets and prep the abx so the oncoming nurse would have as few things to do as possible.
Pt has had PICCs in the past but has had issues with them. Last visit it couldn't be advanced so it was made into a midline which then started leaking. So they may be avoiding centrals for this reason. We run the Vanco with a flush.
The reality is by the time you premed, get a 2nd RN to check and then infuse, the antibiotic will be at least an hour late. My gut said platelets first so I was surprised by the senior nurse's response.
However I do work Onc and we have patients sitting at these low levels often for days on end, especially if they aren't getting a bump and are awaiting HLA matching results or if HLA matched products aren't available. I am hyper aware of complications which might arise from low platelets because those are always a possibility even with transfusions on board in this population.
Platelets first. At my hospital' date=' you're allowed some wiggle room re: med times. It is possible that both can be given in rapid succession and the abx will not be late. If I was the off going nurse, I would start the platelets and prep the abx so the oncoming nurse would have as few things to do as possible.[/quote']We aren't allowed to prep the antibiotic unless we are the one hanging it. It can't be primed and hanging on the med cabinet for example or in the room unless it's infusing. We have an hour before and after med time but with premeds and checking with a second RN for platelets the antibiotic would probably be at least an hour late.
We aren't allowed to prep the antibiotic unless we are the one hanging it. It can't be primed and hanging on the med cabinet for example or in the room unless it's infusing.
We have an hour before and after med time but with premeds and checking with a second RN for platelets the antibiotic would probably be at least an hour late.
You mention the patients platelets have not been increasing despite the transfusions. Not sure if the antibiotic is vanco or something else but possibly it is one that induces thrombocytopenia and the platelet transfusions are simply to maintain the level during treatment?
Yes, C is for circulation in that a possible future complication, especially since your patient has MRSA, a documented infection, low platelet count, DIC could potentially happen. If that's the case, platelets could be a difference between life and death, especially since you said this patient is staying at these levels. Explaining this to the oncoming nurse and M.D. I hope would be sufficient. You might get a wiggle finger from pharm if they ordered a peak and trough, but that could be shrugged off. Also, one potential side effect from vanco is abnormal bleeding or bruising. If your platelet count is low and you have any kind of bleeding, your body will have a heck of a time combating this without sufficient clotting factors.
If the patient is habitually "chewing up" their platelets above a certain count then transfusing platelets is of no benefit and just wastes valuable platelets. There are various potential causes for this, particularly in oncology patients. As you've apparently discovered, their platelet count will be the same whether or not they get transfused. If it's just treating a number (that won't change with platelets anyway) I'd give the antibiotic first particularly if it's a short half-life antibiotic.
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