Prioritizing infusions

[sistrmoon]

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.

[OCNRN63, 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.

Well, I have 29y exp., and I say hang the platelets. That's a critical value and the pt. is at risk for bleeds. Once you run the first 15 minutes slowly, you can run the remainder wide open if the pt. tolerated the first 15 minutes with no sx. of reaction. If the pt. was septic I might reconsider.

[KelRN215, BSN, RN]

The platelets are ready as in, you have them in your hands? So you only have a half hour to hang them from when they arrived from the blood bank, right? I'd hang the platelets. If they go up at 06:20 and run for an hour, you can hang the antibiotics immediately when they're done and get right back on the schedule it's been on for the next dose.

[Esme12, ASN, BSN, RN]

Hummm...I would probably hang the platelets but Muno has a really good point....

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.

Frankly I would be sure to address with the patient and MD that this patient needs a double lumen something.

What was the antibiotic?

[sistrmoon, BSN, RN]

The platelets are ready as in you have them in your hands? So you only have a half hour to hang them from when they arrived from the blood bank, right? I'd hang the platelets. If they go up at 06:20 and run for an hour, you can hang the antibiotics immediately when they're done and get right back on the schedule it's been on for the next dose.[/quote']

No, the platelets are ready as in blood bank has them ready. So you still have to put the blood product delivery request in the computer, print it out, fax it(yes it doesn't automatically go to blood bank. Inefficient.) Then wait for them to be tubed(typically 10 minutes but can be longer at peak times) then find another RN at the busiest time of night shift to check them. *Then* hang them.

[sistrmoon, BSN, RN]

Hummm...I would probably hang the platelets but Muno has a really good point....Frankly I would be sure to address with the patient and MD that this patient needs a double lumen something. What was the antibiotic?

Vanco.

[MunoRN, RN]

Vanco.

Vanco has a long half-life so it's timing is fairly flexible, although I would confirm any timing changes with pharmacy.

You mentioned that the platelet values haven't changed despite transfusions, are the platelet counts always 7,000? "Refractory thrombocytopenia" occurs in about 15-20% of patients undergoing cancer treatment, which basically means their body will maintain a static level of platelets, sort of like they have a bucket that will hold 7,000 platelets, it doesn't matter how many you pour in the bucket, it will return to 7,000 relatively quickly.

[malestunurse]

Platelets. We have to hang platelets within 30mins of receiving them.

[akulahawkRN, ADN, RN, EMT-P]

I'm still but a student, but to me, logic dictates that you hang the platelets first because they're critically low and you can potentially run them in over a total of 30 minutes. You just can't do that with the Vanco. I think that in the end, both will be LESS late if you go platelets then Vanco.

[tokebi]

I would've started platelets first as well. Once transfusion is started, finishing it and hanging antibiotic right after is less work for the on-coming shift. I wouldn't worry about an antibiotic being late an hour too much, unless it is the first dose that needs to be started ASAP in a febrile patient.

But like Muno said, giving platelets after platelets to a refractory pt seems like a huge waste. I hope the MDs are addressing the cause of thrombocytopenia rather than just transfusion after transfusion.

[Anna Flaxis, BSN, RN]

Did you already have the Vanco? If so, I would hang that first since you already have it in hand, then while it's running, work on the computer entry/paperwork/faxing/etc. for the platelets so they will be tubed in time to hang immediately after the Vanco.

[akulahawkRN, ADN, RN, EMT-P]

Did you already have the Vanco? If so, I would hang that first since you already have it in hand, then while it's running, work on the computer entry/paperwork/faxing/etc. for the platelets so they will be tubed in time to hang immediately after the Vanco.

Being that the "actual" time this kicked off was 0620, if the Vanco is actually in-hand and ready to hang, that very easily could change the situation. In that specific situation, I'd go with the Vanco first as well and do the paperwork for the platelets so they're ready to go when the Vanco's done. However, if both have to be obtained/prepped, then I'd say go with the platelets first.

That's what I get for assuming that both have to be obtained first...

[AgentBeast, BSN, RN]

Sort of depends on the clinical situation. Too little information is provided here. I agree with those that state the patient should get a PICC line given the likely need for longer term IV antibiotic therapy.