Can anyone share with me how Vancomycin is given at other facilities. We have many inpatients receiving Vancomycin via peripheral IV sites. This is poorly tolerated in many patients and requires sometimes daily site changes due to phlebitis, even though we are hanging this with a flush bag running at the same time for dilution. Pharmacy wants the Vanc to infuse at 120ccs/ hr for therapeutic levels to be reached.

If the physician refused to

If the physician refused to listen to the evidence - pH and the studies that show 100% phlebitis rates - then I would refuse to give the drug as ordered, especially through a midline. If you can not place a PICC or the patient refuses to have any type of CVC, I would explain the risk and benefits again to see if they would change their mind. If not, I would only infuse Vancomycin through the smallest gauge peripheral catheter in the largest possible veins, always avoid areas of joint flexion but use a handboard if the hand or wrist is required, never use the antecubital fossa for PIV, ensure proper catheter stabilization with a manufactured stabilization device, ensure that you can always get a blood return from the site before each and every dose and restart the catheter if not. Be sure you tell the patient about the risk of extravasation and the frequency of venipuncture with this method. In my opinion, the patient is the only one who can make the decision to go this route. It is not appropriate for the physician to unilaterally make this decision for the patient. There are risks of tissue necrosis with extravasation. Your responsibility would be to thoroughly document what you did, what you taught the patient, and your thought processes for the decisions you made. If there was a lawsuit, your documentation is the best thing you can produce from the medical record to support that you followed the national standards of practice. Lynn

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

What are the legal risks

What are the legal risks that a nurse takes upon her/himself when a patient is ordered Vanco given through a midline when the doctor refuses or it is not possible to thread a PICC? What about when the patient refuses a PICC or other central line access?

There is at least one case

There is at least one case study of using hyaluronidase SC for vancomycin extravasation. Also check the osmolarity of your final compound. If hypertonic always use cold. If isotonic or hypotonic, use heat or cold depending upon the patien's reported comfort level. Heat exacerbates an extravasation or infiltration of hypertonic fluids. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

does anyone have any

does anyone have any recommendations for treatment of extravasation of vancomycin?

This is also a MAJOR problem

This is also a MAJOR problem in our infusion center, but I have a place onthe orders that staes if greater than 3 days of ANY vesicant or irritant a central line will be placed.  should I receive an order from a physician that states peripheral, i am on the phone with them discussing the potential problems.  Some are reluctant, but others listen.  For the ones that do not order a central line, I document the discussion with the physician re: central line placement.  Many patients do not want to be "stuck" every three days, but with these medications it is not unusual to be "stuck" every infusion.

Now, in the main hospital setting, I have no control, but I am attempting to set up a Vascular Access Consultant for patients admitted with osteomyletis, MRSA, etc that will require long term antibiotics or other vesciant/irritant drugs.

 Very common problem seen

 Very common problem seen at Long term care facilities.  MDs do not care (that is a quote) about INS standards and "hospitals do it this way all the time".  I think the only effective way is to educate the patient if possible as to the risks and hope they refuse a PIV and demand a central line or another drug.  And fight via Risk management and Nurse management, and pharmacy to create a policy that drugs with a pH less than 5 must be given via  a central line. ALL THE TIME.  Even one dose can lead to a law suit.  Although, I have worked for a company that did outpatient infusions at MD offices and had such a policy.  When I tried to fight for a central line for a pt on Vanco, I was told I was making trouble and they would just "watch" the site with each dose.  I never went back so I have no idea what happened with that patient.  Not sure how you can win without having the patient refuse treatment.  

Chris Cavanaugh, CRNI

Clinical Educator

I don't know how other

I don't know how other hospitals do it, but at our hospital, we get a lot of homeless people with some sort of cellulitus brewing somewhere.  In anticipation of it being MRSA, the MD's will put the pt on Vanco upon admission then change the drug if needed once the cultures come back.  If I had to put a PICC in every single one of these pts, I wouldn't have time to get to anybody else!!!  I actually encourage the MD's to hold off on the PICC orders until we get cultures back.  Maybe we could start presenting some sort of literature to MD's that a pt should not be put on Vanco until it is confirmed MRSA.  Any opinions on this or anybody know of literature that supports this?

Kristin Walker RN, BSN, OCN Maui Memorial Medical Center IV dept.

      I have attached

 

    I have attached a nice example of what Vancomycin can do peripherally in one dose. It took us two years and several extravasations, but we showed the docs every single time we had one, and charted to make them responsible for it.  It was amazing how quickly they started asking for PICC's.  They sometimes even jump the gun now, and ask for a PICC before culture results are even back. It is a lot of work, but changes can be made, even one patient at a time. 

I have this problem as

I have this problem as well.

You could look into instituting the assessment advantage program

you can try to go through the channels to make policy that states this should be run by central line. MDs cannot override policy

working with Pharmacy to capture the patients that are on vanco. --or to take on this challange would be ideal

you must have enough staff to be able to institute this kind of practise change as it will then have to be consistant. Otherwise you would just have to champion for each individual case that you think warrents a PICC or CVC

O.K....So basically it won't

O.K....So basically it won't matter how the Vanc is run it is a vesicant. How should I go about attempting to change the way this is being done? Most of the physicians are reluctant to have central lines (including PICCs) placed unless there just aren't any peripheral veins left. How many days of a vesicant require central access and where can I find the documentation to support this?

o.k. So basically it won't

o.k. So basically it won't matter how the Vanc is run through a peripheral line, it is a vesicant. How should I go about attempting to change the way this is being done? Most of the physicians are reluctant to have central lines (including PICCs) placed unless there just aren't any more peripheral veins left. How many days of a vesicant require central access and where can I find the documentation to support this?

PICCs or any type of central

PICCs or any type of central venous line is recommended. The problem is the pH. This will always be less than 4, regardless of how it is admixed. Vancomycin is also a vesicant. So if you have extravasation, there is a good chance for nasty tissue necrosis. The only time it might be given through a peripheral vein is for a few doses pre-or post op, but that is not the recommended usage for Vancomycin. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Jan Hull BSN,CRNI IV therapy

Jan Hull BSN,CRNI

IV therapy & Infusion Services Manager

Samaritan Lebanon Community Hospital

541-451-7851

fax 541-451-7520

We place PICC's for these folks.