question about vanc, trough, and holding the dose

roma4204, BSN, RN · Sep 19, 2011

Ask the pharmacist. Simple solution!

birdie22 · Sep 19, 2011

i dont really know the answer to this...but in my experience where i work, if they come back high, I let the MD know, they usually tell me to hold it and then just give the next scheduled dose. I always ask them if they want a redraw, and I've only had to do it if the level is crazy high.

IVRUS, BSN, RN · Sep 19, 2011

Hello! I am a new nurse, only 9 months old, and just have a quick question about vancomycin. When the Dr order is written to draw a trough every third dose, and hold if say over 12, and the level is high , lets say 14, so you hold the dose. So you didnt give the third dose. Do you automatically need to redo the trough before the next dose since its technically still the third dose, or do you just give it and hope the levels have dropped enough? Thanks for any input!

The Md needs to be specific about his or her orders.. i.e. Hold next dose than draw another trough before tomorrow's dose and call results.. or Hold next dose and give the AM dose tomorrow after trough is redrawn...

Don't try to guess, or ASSuME what the MD wants. That only gets you in trouble.

SuesquatchRN, BSN, RN · Sep 19, 2011

I had this come up ystdy. Crazy high trough, pharm looked at it and it turned out the trought was timed incorrectly, drew another 1/2 hour before next dose, WNL, gave next scheduled dose.

There should be a policy in place regarding it, no?

shygoofyone · Sep 19, 2011

Our physicians usually defer to the pharmacists by writing "Vancomycin-pharmacy to dose and manage." And, we've recently found out that our lab's "normal limits" is actually lower than the recommended levels for certain treatments, so it's really nice having pharmacy reviewing the labs. Plus, they are the ones mixing it based on each day's trough, so the nurses are not being put in the position of determining treatment. The bad side? Some newer nurses aren't even realizing their patient's troughs, because "well, pharmacy is managing it..." (hate that excuse! You should still know!)

jujuseah, RN · Sep 19, 2011

Ask the doctor to write down in his notes when to restart vanco. Usually they will check vanco trough again before starting. It is important to ask him to restart when and check if bloods are needed! It is annoying because usually we do vanco trough at 6am before giving the morning dose (at 8am) but nurses in singapore are quick to give the antibiotics like 7 am and then we see the vanco trough results, we would be like oooops, we didnt get the results yet muhaha but usually it shld be okay unless they do vanco peak then its different to overdose the patient.

LouisVRN, RN · Sep 19, 2011

At our hospital you hold a dose if its over 20ug/mL. But you only hold it until the physician/pharmacy re-configures the dosing. Like if they were getting 1gm q8 hours and the trough came back at 25ug/mL. You'd anticipate maybe having the order changed to 1gm q12 hours. So giving a dose maybe 4 hours after the original (held) dose was due.

Also all of our troughs are timed for 1/2 an hour before the next dose? Is that not standard practice? If they are rechecking a vanco level at a time not 1/2 an hour before the next dose we consider it a random Vanco level, not a trough. I was under the impression that peaks and troughs had to do with the half life of the medication and would always be a certain amount of time away from a specified dose.

DookieMeisterRN · Sep 20, 2011

Our pharmacists manage all vanco dosing but if yours doesn't always clarify with the MD if there isn't clear parameters.

avidhunter3 · Sep 20, 2011

thanks everyone! As far as parameters, at our hospital it is always trough every third dose, and hold according to what the DR sets, usuall hold over 12 or 14. My question was just something I specifically wondered about, that if the orders say to do a trough every third dose, and you HOLD the third dose due to it being high, wouldnt you automatically reorder another trough for the next dose, as its still the third dose? Not to mention, if it was high on the last trough, wouldnt you want to recheck it? Normally everyone just gives the next dose and never does another trough, I just wondered about it.