Vancomycin infusion after allergic reaction

[phoebebrat]

Has anyone been ordered to give Vancomycin after that pt already had an allergic reaction to it?:uhoh21: I took over care of an 18y.o. that was to get another vanco. infusion on my shift. The dr told me that he already had a reaction of Red Mans Syndrome and hives, along with pruitis. The dr. told me that I would premedicate the pt with benadryl before the vanco and to "have epi on hand in case of another allergic reaction." About half way through the vanco dose the pt presented with eyrthema, pruitis, and swelling to the lower eye lids. At that time I gave him the minimum epi. dose. An hour later his color had returned to normal. The dr. asked me if the pt had difficulty breathing before I gave the epi. He did not, I didn't think I should wait until his airway was compromised to take action. As it turned out, the pt. was fine and I was terminated. I need your opinions! Help!!!

[justme1972]

See, as a student, posts like this scare the **** out of me.

For educational purposes...what would could have been done differently?

I'm only 2nd semester, 1st year...my thinking is that you wouldn't administer the Vancomycin at all if the patient had already had an allegic reaction (based on the described symptoms of previous administration).

So, if a nurse were to make that choice NOT to administer b/c th patient described an allergic reaction...what would have happened next?

We were taught that regardless of the drug, if a rash/hives had developed in a first reaction, under no circumstances was the med to be administered again.

Then again...I'm a first year student and am probably not aware of any exceptions made in the field.

This would be a great opportunity for us to learn from the veterens on how to handle these situations!!!!!!

[PsychNurseWannaBe, BSN, RN]

dirty, dirty stuff...

I personally would have refused to give the med if the pt had a previous allergic rxn. But sheesh, I am so sorry that they really ran you through the wringer! I would like to pow pow pow that Nurse Aunt for you. I hate dirty nurses...

Hugs!

:yeahthat: I wouldn't have done it. I would have contacted my charge nurse. I am very skiddish about these types of things. And that Nurse Aunt ...ugh! So sorry for what you are going through. You can either fight to get your job back or move on. If this place has nurses who like to play dirty pool, then I would move on.

[withasmilelpn]

I have heard that doing something that is 'reasonable and prudent' in an emergency situation can cover you if no doctor is immediately available to give you an order. Has anyone else heard this?

[withasmilelpn]

I forgot to ask, did any actual harm occur?

[EricJRN, MSN, RN]

We were taught that regardless of the drug, if a rash/hives had developed in a first reaction, under no circumstances was the med to be administered again.

You would almost always be correct. There are some no-win situations in prescribing antibiotics though. Owing largely to liberal use of antibiotics in the past, physicians have fewer options to treat each organism. Sometimes they have to consider the seriousness of a previous reaction when deciding whether to give it again.

This situation comes up sometimes with patients who have pulmonary edema and require Lasix. It ideally isn't given to patients with a history of sulfa drug allergy, but if it's for an emergency (especially prehospital where no alternative diuretic is typically available), decisions have to be made. If the patient's previous reaction to sulfa was a non-urticarial rash or a tummyache, they're getting Lasix.

Red man syndrome (RMS) does involve histamine release and effects on mast cells, but we can reduce the risk by giving it very slowly. Interestingly, research shows that healthy volunteers receiving Vanco were at higher risk for RMS than patients with infections.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=270616

It sounds like they're hanging the OP out to dry on an issue that could have at least been resolved with some counseling.

[cardiacRN2006, ADN, RN]

See, as a student, posts like this scare the **** out of me.

For educational purposes...what would could have been done differently?

If it were me? I would not have administered the Vanco in the first place.

Secondly, when the allergic reaction occurred, I would have had another nurse page the dr as I drew up the epi and stopped the Vanco, aspirated the line, etc...

When the Dr picks up the phone, I would have said, "Pt so-and-so is having another allergic reaction to the Vanco. I am giving X mgs of epi for the Vanco allergic reaction and I need an verbal order for it, and I need an order to D/C the vanco. What else would you like me to do?"

[medsurgrnco, BSN, RN]

When the doctor told you to have the epi on hand, you should have told him that you needed a complete verbal order and then written the order in the patient chart. With no dose or route information, you did not have a verbal order. I also would have discussed the situation with the charge RN before giving the vanco. Seems like some nurses can make lots of mistakes without termination, while others are quickly terminated. I've worked at hospitals with no standing protocols. In emergencies if you can't reach the doc fast enough, you call rapid response. And you could override to obtain meds in the pyxis.

[Scrubby]

I personally would not have administered the Vanc unless the doc had written down some very specific orders on the epinephrin/adrenalin. I'm very wary on verbal orders as you have described because all too often people just want to cover their own butts if it hits the fan.

I don't believe you did the wrong thing for the patient and IMHO termination was a complete overreaction. But i do think you need to be more careful about documentation. The patient was known to have a history of red mans syndrome, the risk was clear to the doc who even mentioned he may have needed epi, there really should have been a clear written order just in case it was needed.

[EmmaG, RN]

Thanks again for everyone's reply. Technically according to DON there was not a legal order for the epi. I thought that I had a verbal order. DON says that I have no right to write my own orders Everything happened as I stated. Pt. was fine after epi dose. for a high alert medication, although that was not my intention. I was supposed to call the ER dr, yes, and wait! BTW, I have never had a verbal or written warning before this incident. IN is an "employment at will" state. I may contact a nurse attorney for advice but don't know if I can have this taken off my record.

Ok, I'm still confused.

"I thought he gave me a V.O. for the epi and just forgot to tell me the dosage."

All of the other details you're giving here seem to detract from the main issue:

Did you have a complete and legal order from the physician to administer the epi? As in dosage, route, frequency, indication, etc.? You keep saying you "thought" you had a verbal order, but state above that he 'forgot' to tell you the dosage. And yet you gave the med anyway. That's practicing medicine without a license, ya know.

[phoebebrat, ASN]

Please bear with me, this is going to be long but I'd like to respond to some of the additional responses to my post. You know what they say "Hindsight is 20/20." I would have done things so much differently if I could do them over. First of all I would have refused to even give that Vancomycin. I should have let the charge nurse handle the whole situation. I also should have noticed when the dr. was talking to me about the....."have epi on hand in case of another allergic reaction" statement that I should have asked more questions. I was just stunned that he wanted me to do such a thing and got so caught up in my own thinking and fear about allergic reactions that I failed to see that I didn't have a complete order. I hadn't even had report on the patient yet, I had just walked into the shift and the dr. stopped me right away to tell me this stuff. I still had my coat on and bag in hand.:stone I completely feel like I was the lamb led to slaughter and I willingly walked right into the firing zone. When the dr was telling me what I would be doing I also had a quick thought that he must have already wrote the epi order and left the thought at that. He did write the order to pre-medicate with the benedryl, and 25mg not 50mg as I have read indicated. (kid weighed around 140lbs., 18y.o.) And what the heck was that statement all about anyway? Have epi on hand...... but don't use it? He might of well have said that. And if I wasn't supposed to use it, why even have it on hand? It wasn't doing me any more good that way than it was sitting in the pyxis. And about the charge nurse, I talked to her about the whole situation during the shift, she asked me if I had an order for the epi and I told her EXACTLY what the dr. said, and she said OK. (her mind must have been on other things too) She was there when I started the infusion, she was there when I found the reaction, and she told me, "you better give the epi now." I said, "I guess the dr. forgot to tell me the dosage, and she said we will give him the minimum dose." I'm the only one who was reprimanded at all over the whole thing. And remember the nurse that violated HIPAA, she didn't get reprimanded either. It was never my intention to "play dr., or practice medicine." My head is still spinning wondering what the heck happened that night. Let me tell you all a little bit more that I found completely confusing about the whole situation. Admitting DX was pneumonia, pt's K+ was 4.1, WBC's were 4,(), BS was normal, and dr. stated that CXR upon admission was much worse than CXR from 2 wks ago. Pt had been treated with po antibiotics with no improvement. I looked at the admission CXR report which was completely negative. K+ was WNL along with BS but IV fluids were D5NSwith 20of KCL. and I think the rate was 125ml/hr. Another thing I didn't understand was that his lungs sounded clear, not only to me but to the previous shift nurse and RT. Thank you to everyone for their input. I have needed the therapy.:bowingpur I'm still trying to put this whole thing behind me. I don't think I want to work in med/surg anymore. I didn't realize just how much my butt was on the line. And Thank You to Eric for the informative link about Vancomycin. I wish I would have read that before this whole crappy situation!

[leslie :-D]

aw, (((phoebe)))..

you were put in an awful situation, and i think you reacted to the best of your ability at the time.

i agree.

why the heck did the md say "have epi on hand"?

dang, even if he didn't say it, administering it would have been the next, life-saving step.

and then, to leave you hanging and out to dry like that???

the whole thing stinks.

and you deserve so much better.

'next time', if any doc ever gives an offhand order like that, you'll know the questions to ask.

'next time', you'll know to defer any incident to next in charge, when that uncomfortable with an order.

you were totally screwed with this situation.

and again, i'm so very sorry.

you sound honest and accountable.

wishing you the very, very best.

leslie

[sfsn]

The inappropriate involvement of the other nurses does seem completely wrong. Especially if Aunt Nurse claims that you gave the whole vial of epi - the patient's vital signs would certainly have shown evidence of that, right?

Also I hope the charge nurse backed you up. If she was there, has more experience, and advised that the epi be given - why should you take all the blame?

And being terminated based on that incident seems totally unfair!

However, I must say that IMHO after reading your description, the patient's reaction did not really warrant giving epi without checking with the MD. I'm not saying that what you did was wrong, because the MD definitely suggested that you should give it. I just believe that from your description it sounds like the patient was probably not in anaphylaxis. Red Man Syndrome is not the same thing - it usually resolves with stopping the infusion and more Benadryl if they haven't had a full dose already. Even if it were a true allergic reaction, epi is not necessarily given - Benadryl, steroids, might be all that are needed. It doesn't sound like this was an emergency situation where you don't have time to at least try to get hold of the MD for a specific order - the pt. could possibly have been heading toward respiratory compromise, but probably not.

Like I said, I am not saying I think you did the wrong thing. I might have done the same given what the MD said. He did use the words "another allergic reaction." Very confusing - if he considered it a true allergy he would not have ordered the vanco in the first place. The whole situation is just really a mess. The MD put you in a really bad position and you were trying to do the right thing - the same thing many other reasonable nurses would have done, I think. So sorry this happened!