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.

[sistrmoon, BSN, RN]

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

I hadn't received them yet. They were just ready in the blood bank.

[sistrmoon, 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.[/quote']

Yes, Vanco was in hand.

[sistrmoon, 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.

See my comments providing further information, especially regarding patient's central line history:)

[Anna Flaxis, BSN, RN]

Yes, Vanco was in hand.

Okay, then if the process for obtaining the platelets is as cumbersome as you described, I would hang the vanco first, while then starting the process of obtaining the platelets. This would be far more efficient.

I could be wrong about this, but I find it doubtful that the patient's platelet count would drop further as a result of a single dose of vancomycin. Vancomycin induced thrombocytopenia isn't all that common, and tends to occur after days of therapy. So hanging the platelets immediately after the vancomycin is infused should be safe.

Again, I could be wrong, but that's what I think!

[PaxRN]

Pharmacy is a good resource for this, since some atb have a lingering window and can safely be given later without any adverse effect. I would have hung the platelets first since they are less likely to mess up the site and they infuse faster. Our unit runs vanc in slow thru a PIV (125 ml/hr max - smallest bag I have seen is 200 ml). Stinks when patients refuse sticks or when docs refuse a central line when patients clearly need one.

[Nurse SMS, MSN, RN]

I would hang the platelets first, explain to the next shift and then they can chart the Vanc as late and give the reasoning. ("Only one line, platelets infusing"). Then I would put a note for the doc to address with the patient the need for a second line. The oncoming shift should not have issue with this and frankly if they do, tough. Given the need for platelets, I would definitely give it priority, particularly if the patient has already been getting Vanc for their infection and the trough has been therapeutic.

[RNperdiem, RN]

Vanco is hard on the veins, especially for someone with poor IV access. I would go ahead and give the platelets while the IV is still good. If the docs decide that they really must put in a central line, then at least the platelets would have been infused.

[wooh, BSN, RN]

In a perfect world, I'd give the platelets first. But if vanc is in hand and it's going to take 15-30 minutes to get the platelets in hand, the vanc can be half done if I go hang it and then deal with getting the platelets.

When was the vanc due? If at 6, and I knew I was waiting on platelets, I'd have planned ahead and had that sucker hung at 5:30 because I always hang my morning antibiotics as soon as I can get away with it to avoid shift change annoyances like discovering a bad IV site when I'm trying to get my ducks in a row to finish things up. It also gives me time to deal with stuff before shift change like platelets that are finally ready in the blood bank.

[Nurse SMS, MSN, RN]

I was thinking that too Wooh....that I would have hung the Vanc up to an hour early to get it in while I get ready to give the platelets.

[rumwynnieRN]

Platelets. It takes longer to hang the platelets, and if the next nurse is upset because "they have to hang something that should've been done on your shift," whatever. It's an antibiotic.

Edit: By longer, I mean cumbersome, and in this situation, if you were waiting on platelets, yeah, I either would've hung the Vanc earlier (we can do our meds an hour early to get them both done, or if for whatever reason you couldn't get to the platelets, leave it for the next shift. Truthfully, I don't care if people leave me stuff to do, but I'd prefer that you got the most cumbersome thing out of the way. I don't care if I have to hang an antibiotic you couldn't get to. You spike it, you're done (assuming you checked your troughs and all that jazz).

[sistrmoon, BSN, RN]

In a perfect world I'd give the platelets first. But if vanc is in hand and it's going to take 15-30 minutes to get the platelets in hand, the vanc can be half done if I go hang it and then deal with getting the platelets. When was the vanc due? If at 6, and I knew I was waiting on platelets, I'd have planned ahead and had that sucker hung at 5:30 because I always hang my morning antibiotics as soon as I can get away with it to avoid shift change annoyances like discovering a bad IV site when I'm trying to get my ducks in a row to finish things up. It also gives me time to deal with stuff before shift change like platelets that are finally ready in the blood bank.[/quote']

Did I also add this patient hates to be woken early to the point she had a sign on the door don't wake til 6? Yeah, it's the perfect storm of fun. And before you say "too bad," these are long term patients we have for months and they do complain about being woken early to our manager and then we are told not to do it. It's happened several times.

Vanco is due at 6.

[sistrmoon, BSN, RN]

Also, platelet transfusion was not ordered until morning labs had been drawn and come back. So yes, this particular patient probably could have been predicted to need platelets(although sometimes they surprise you), but we don't hang them typically except under 10k. There was no standing transfusion order for under 10k. So it's not like I knew for sure I would be hanging platelets until I had the values back and called them.

There's been push for us to draw labs earlier because "night shift is trying to avoid transfusions." But there is also push back from long term patients not wanting to be awakened at 0400 for lab draw. This particular patient was a phlebotomy draw so that happens at whatever time they do our floor.