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The Devil is in the Details

If you look to the right on this blog you will notice that I recently retweeted a great pearl from the Critical Care guys (@critcareguys) about hanging the Zosyn before the Vancomycin in severe sepsis patients.  They remind us that Zosyn has a broader antimicrobial spectrum and goes in faster, potentially offering greater benefit to your sick patient.

This has always been my practice, but I can’t tell you how many times early on in my career I found the Vancomycin hanging first. This used to drive me crazy, until I figured out what was going on. As it turns out this seemingly simple tenant of good care is one of those “devil is in the details” problems that no one tells you about.

Vancomycin is pre-mixed and quickly available in most EDs.  Zosyn is also readily available, but has to be reconstituted, which as any nurse will tell you is a pain in the ass.  Now in the age of EMRs the orders for the Vancomycin and Zosyn are placed together and no face to face communication happens with the nurse.  Now they’re busy too.  They see the antibiotic orders, grab the Vancomycin because it’s premixed, and they have 15 other orders to take care of.  That gives them an hour before they have to shake and bake the Zosyn.  Ta dah! Now you walk into the patient’s room 45 minutes later to see your septic patient with the slow drip of vitamin V instead of Z.

I have a method for dealing with this problem (it’s number 2), but it becomes an issue again if you work with residents or mid-level providers when I ask the dreaded question, “did patient x get the Zosyn?” And the all too common answer comes back “yes, I ordered it”  (which actually means no, or I don’t know to me until proven otherwise).  So unless you know your resident or PA, make sure they know what you want and what they have to do to make it happen.

So there you have it.  I have tried all three of the methods below to make sure the Zosyn goes in first.  Anybody else have a method?

1.  Put the Zosyn order in first,wait 20 minutes, and then put in the Vancomycin order. (Time consuming, inefficient, and not guaranteed to work)

2. Just talk to your nurse and tell them what you want first and why. (your best bet, and it fosters communication..if you like that sort of thing)

3. Hide the Vancomycin until the Zosyn is hung. (just childish)

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3 replies »

  1. You’re absolutely right Scott,
    Thanks for always cutting the Gordian knot. In the clearly sick patient access is the solution to many problems, including which antibiotic goes in first. When I wrote the post I had in mind my daily reality of the many patients in that indeterminate zone: they have one IV initially (maybe it was hard to get and you don’t want to go looking with the ultrasound, or put in a central line just yet). The patient is stable, but your on your guard, and you want the broadest coverage to go in first just for your peace of mind. Your giving them that first 500cc of fluid along with it to see what their vitals do and waiting for your labs, vbg, and lactate to come back and seeing where you stand after that. Thanks again and have yourself a great 4th of July.

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