Vancomycin infusion after allergic reaction

Nurses General Nursing

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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." :eek: 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!!!:crying2:

Question for sfsn. I was wondering if you also saw that I had written that pt also had hives with first infusion. With the second vanco infusion, the one that I administered he had the RMS, pruritis, and swelling to the lower eyelids. I haven't seen a full blown allergic reaction and know that in this case it wasn't one. I was just thinking that resp. compromise would be next. Could you explain more to me about the sequence of anaphylactic responses?

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Specializes in Post Anesthesia.

I would have clarified the order for epi when it was given-"do you want me to give epi if I see a reaction" and by all means I would have called the doc after I saw a reaction and treated it. If the patient was having an anaphylactic reaction to the vanc he needed follow up treatment-it wouldn't wait for morning rounds. The epi is just a stop gap measure. Perhaps it is the delay in follow up that is causing the hoopla. As far as the nurse/aunt- I have no idea what part that might be playing. What would a "reasonably prudent" nurse do?- well, by that standard, if you felt the patients life was in immidiate peril you acted correctly with the epi, but still- ya gotta call the doc!

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Question for sfsn. I was wondering if you also saw that I had written that pt also had hives with first infusion. With the second vanco infusion, the one that I administered he had the RMS, pruritis, and swelling to the lower eyelids. I haven't seen a full blown allergic reaction and know that in this case it wasn't one. I was just thinking that resp. compromise would be next. Could you explain more to me about the sequence of anaphylactic responses?

I'm sorry, I didn't remember that you mentioned hives. And I agree that respiratory compromise might have come next. As far as explaining the sequence of anaphylactic responses, I don't presume I know any more than you do.

In my experience, RMS usually includes pruritis and sometimes even some mild facial swelling. I guess it's a fine line. I just think, I have seen RMS frequently enough w/ Vanco that I would normally expect any reaction to be that instead of anapylaxis requiring epi. I guess my point is that from what I understood of your story, I would not expect an MD to order epi in that situation. At least not as the first step in treatment. But the way this patient was presented to you, and what the doctor and charge nurse said, I don't think you were wrong in what you did!

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What an interesting thread. Great example of why physicians need to be absolutely clear about their orders, and why the aggrevating "read back" is so important when giving/taking verbal orders.

Couple things that struck me about this whole deal:

1) I would never give a standing order for epi. Ever.

2) Even if I did give a standing order for epi, the indication would absolutely not be "anaphylaxis". That's a constellation of symptoms, and the interpretation of what constitutes it is open to interpretation. The indication for giving a standing order should always be a single symptom, like "respiratory distress".

3) My hospital does not permit orders to "Keep med at bedside". You can only order a med if you're going give it, and it can only be pulled out of the Pyxis when it's going to be administered. This can be frustrating, especially with the slower nurses, but I guess this story is precisely why they maintain that policy.

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Specializes in CNA, Surgical, Pediatrics, SDS, ER.

I'm so sorry for your situation. :(It sounds like you got the short end of the stick. I think that firing you was way over the top.

He probably shouldn't have ordered the Vanc if he knew this pt had an allergic reaction to it and if he did not want epi to be used then he should have never uttered those words. You did also have the charge tell you to give the epi so I don't see how they are condeming you and no one else involved.

I don't think that what you did was wrong by any means considering your situation, however I would have for sure got the epi order clarified if I were going to give the vanco. There were also many other factors that played a hand in what happened to you. Those two nurses had no business taking this situation into thier hands esp. not knowing the circumstances at hand. They probably played a larger role in you getting fired than anything else that occured. :nono:

I'm sure you gained a valuable lesson from this experience and you won't let it happen again. You are responsible for you and you have to keep all of your bases covered because in the end all you have is your documentation. None of those people admin, docs, other nurses will go to bat for you, sadly everyone is out for themselves. Administration sucks and they are only interested in protecting/covering their own a** 9 times out of 10 they won't back you.

You sound like a good honest nurse and I wish you the best of luck.

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Specializes in Cath lab, ICU.

What a coincidence!! Just yesterday i had a bad reaction to an infusion of Vanc!! There was no documented allergy to this antibiotic, but others. The reaction did not start until 15 min. after the infusion was done!! RMS ws present, hypotension, drop in oxygen saturation, tachycardia and respiratory wheezing. Benadryl, solumedrol and small amount of IV epinephrine took care of the situation. Standing orders are a must in any unit when NASTY drugs like vancomycin are given

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phoebebrat - listening to your story it sounds like you did the right thing for the patient, but unfortunately to spite yourself. .3 of epi sub q won't hurt any 18 year old. The doctor from Clinica Malpractica needed to be paged the moment the reaction started, and you turn off the drip. I'm sure waiting a few hours until he would come in seemed like a good idea at the time, but come on. It's your license on the line... he needed to make decisions, isn't that what the MD is supposed to do. It's definitely something we can all learn from.

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