HyperBananaNemia

Thought this blog could use some pictures!

AKA hyperkalemia.

Electrolytes 
There was a patient last week on Wednesday who came in with pretty bad hyperkalemia...with a K level of about 8.5. I learned that the first thing the patient is given is calcium gluconate. After that, there are two options: either eliminate the potassium in the body (dialysis, diuretics, Kayexalate) or move the potassium intracellularly (albumin, sodium bicarbonate, dextrose/insulin).

Psych
Flumazenil reverses benzos, but if this happens too quickly, it could lead to seizures :(.

Renal 
No Lovenox or Bactrim for renal failure.

Infectious
The PO equivalent for Zosyn is Augment. The PO equivalent for Vancomycin is Bactrim. Max dose for clindamycin is 1.8g and IV max is 3.6g.

Anticoagulation
There was a patient in last Wednesday, and the doctor was wondering whether or not the patient should be bridged on heparin while restarting his warfarin therapy. There are some factors that need to be taken into considering to answer this question. The first is whether the patient is at a low, moderate or high risk for clotting. High risk patients would include a mitral valve replacement (MVR), old aortic valve replacement (AVR), A-fib, history of thromboembolism in the last 12 months. Moderate risk patients include AVR with DM, HTN, CHF, >75 y/o, OR stroke. If moderate risk, then bridging therapy is recommended with therapeutic dose LMWH, low dose LMWH, or UFH. HOWEVER, this is a 2C recommendation, meaning it's not that great of a recommendation and the amount of research out there isn't impressive. If high risk, then bridging therapy is recommended with therapeutic dose LMWH or UFH, and this is a 1C recommendation, meaning it's a good recommendation and the amount of research out there isn't impressive. My preceptor said 1C recommendations are good to follow, but not really 2C. The specific patient I'm talking about was at moderate risk, so the doctor decided not to do bridging therapy, and the pharmacist agreed.

Gases
BiPAP vs. CPAP. Bi-level positive airway pressure and continuous positive airway pressure. Both are for patients to get more oxygen into their systems. The difference is that for BiPAP, the air pressure decreases when the patient breathes out, so they're breathing against less pressure. With CPAP, the pressure level is continuous. I can finally tell if someone is in respiratory/metabolic acidosis/alkalosis quickly (I know, about time, right?). So basically, First look to see if the pH is acidic or basic. If acidic, then look at the pCO2 level. If it's high (>45), then you're looking at respiratory acidosis. If the pCO2 level is NOT >45, then you're thinking metabolic acidosis, but take a look at the HCO3 just to be sure (if it's <22, then it's confirmed). If the pH is basic, then look at the pCO2 level. If it's low (<35), then it's respiratory alkalosis). If the pCO2 level is NOT <35, then you're thinking metabolic alkalosis, but take a look at the HCO3 just to be sure (if it's >26, then it's confirmed). If it's a respiratory disorder, then the pCO2 goes in the opposite direction of the pH. If it's a metabolic disorder, then the HCO3 goes in the same direction of the pH. For compensation, the pCO2 will compensate for metabolic disorders by going up if alkalosis and going down if acidosis. For compensation, the HCO3 will compensate for respiratory disorders by going up acidosis and going down if alkalosis. Lastly, if PaO2/FiO2 is <300 then this is Acute Lung Injury...if <200 then it's Acute Respiratory Distress Syndrome. FiO2 is fraction inhaled O2.

Patient Case
There was a patient last week who was sedated beyond belief when we went on rounds. He could barely wake up, even when the doctor shook him. He was given diazepam the day before for alcohol withdrawal. However, the doc had discontinued the patient's benzos and narcotics the day before, because he was concerned about him going into severe respiratory distress. When we went in to check on him, he could barely answer any questions. Turns out he was given 8 percocets within 16 hours. ABGs were done on him, and his pH was 7.2 something and pCO2 level over 100. 0.4mg naloxone was given to him to reverse the narcotic overdose, and I was amazed with how fast it worked. The patient was literally able to answer questions within about 45-60 SECONDS. A few hours later, pCO2 level was <60, and he was improving.