So, I’ve heard of Code Blue, but anyone heard of Code Brown? Thankfully I asked my preceptor what exactly Code Brown entails before saying something embarrassing. “Code Brown” = when a patient has C. dif, and (for lack of better words) takes a huge dump and it gets everywhere!
Today [5/19] was my third 10 hour day, but the time is starting to go by faster J. Learned a lot, as always.
Anticoagulation
Heparin-induced thrombocytopenia. I did some research on this topic today, and I’ll now attempt to type up everything I remember. There are 3 types of HIT: type 1, type 2, and HITT. Type 1 is not immune-mediated, and it happens when heparin directly activates platelets, and aggregation begins. Type 2 is the clinically relevant HIT. Basically, if a patient has a type of anti-PF4-heparin antibody, then it will see the heparin-PF4 complex as a threat to the body and begin the immune response…eventually resulting in a high risk for thrombosis. BTW, PF4 stands for platelet factor 4. It’s just a pretty crazy paradox, because a blood thinner eventually causes high risk for clotting. The treatments are direct thrombin inhibitors like bivalrudin, lepirudin, and argatroban. There’s also a factor Xa antagonist called danaparoid that can be used. Why wouldn’t warfarin be used? It’s because of the initial procoagulation effect of warfarin via quick depletion of proteins C and S. So, it’s generally recommended to stay off the warfarin until INR is therapeutic, and possibly bridging him onto the warfarin. Also, HIT is diagnosed by the 4 T’s: timing, severity of the thrombocytopenia, the occurrence of new thrombosis, and the presence of alternative explanations for the thrombocytopenia.
Infectious
Atypical pneumonia. Bugs: Legionella pneumonia, Mycoplasma pneumonia, Chlamydia. Drugs: I believe these bugs are covered by azithromycin, clarithromycin, erythromycin, fluoroquinolones, and tetracyclines. With C. dificile, there are two main therapies: metronidazole (500mg TID for 7-14 days) and vancomycin (150 or 250mg QID for 10-14 days). Metronidazole is for low risk and vanco is for high risk. Hospital Acquired Pneumonia. Something I learned about HAP – the risk factors for this include previously being in a hospital for 72 hours or more within the past 90 days, being in a hospital in general, antibiotics, and being immunocompromised. Ampicillin/sulbactam covers Gram positive, negative, anaerobes, but NOT pseudomonas. Piperacillin/tazo covers the same plus pseudomonas. For aspiration pneumonia, you want to cover anaerobes. Ampicillin has a 50% bioavailability, and amoxicillin has a 80-90% bioavailability.
Labs
If BUN is increased, then it could be due to things like kidney dysfunction or upper GI bleed (labs will show decreased H/H). Fever is defined as a temperature of 101’F one time or 100.4’F x2. The FeNa is the fraction excreted sodium. The equation is: [Urine Na x Urine Cr]/[Serum Na x Serum Cr] x 100. If this number is >1.0, it’s not prerenal kidney injury. If it’s <1.0, it is prerenal kidney injury (so think dehydration/hypovolemia).
P.S. If I didn’t make it clear enough, Code Brown isn’t a real code!
Don't forget that the vanco for C Diff is PO- vanco is not absorbed through the GI tract. Also, the vanco capsules are pretty expensive so hospitals will compound the oral solution from the IV formulation and dispense it that way. You can save a patient a lot of money by compounding the oral solution for the outpatient pharmacy when the patient is discharged...
ReplyDeleteInteresting, thank you! So, in this case, PO isn't actually referring to the capsules, it's referring to an oral solution. Is this correct?
ReplyDeleteAlthough the capsules are available (and are used) a lot of institutions will use the oral solution... so, yes, PO may refer to the solution. If not, then suggest it because it can save the hospital and the patient money!
ReplyDeleteTry taking a peek at fidaxomicin. I've only looked through the phase II and phase III trials superficially, but it looks promising.
ReplyDelete