A bottle of gatorade...

...has 3 mEqs of potassium! We had a patient last week whose hyponatremia (low sodium) was getting worse and worse because he was constantly drinking water or eating ice. He had xerostomia (lack of saliva...dry mouth), which explains his constant fluid intake. Since his hyponatremia was worsening, he was put on fluid restrictions. He wasn't okay with this, so the medicine team let him have gatorade. The next day we checked his electrolytes, and his hyponatremia was improving, but his potassium had increased more than we'd like. We went to his room, and there were about 4-5 empty gatorade bottles laying around the room, which led us to look at the label:

Potassium = 30mg per serving x 4 servings = 120mg.

If 1 mEq = 39mg of potassium, and each bottle has 120mg, then each bottle has about 3 mEq of potassium.This isn't actually a whole lot per bottle, but it could be a significant amount if the patient drinks a ton in a day.

Electrolytes
At the end of certain days we have "family rounds," where the three students doing the acute care rotation and our preceptors sit around and discuss some interesting patients. Instead of presenting a patient case last Friday, I decided to discuss the calcium-phosphate equilibrium (which, let me tell you, is an exhausting topic). So calcium and phosphate are important for our bodies to function, and it's important to have the right amount of both. Parathyroid hormone and Vitamin D both act to increase the amount of calcium (PTH tells osteoclasts to bring down bone to bring Ca into the blood and tells the kidneys to excrete more phosphate and reabsorb more Ca into the blood, and Vitamin D absorbs more Ca from the intestine into the blood). The main thing I was explaining last week was how kidney dysfunction relates to Ca-PO4 equilibrium. If a patient's kidney function decreases, then two important things (among others) happen: there's more phosphate in the body since it's not being excreted, and vitamin D isn't being turned into its active form by the kidneys. The decreased vitamin D means there's decreased absorption of calcium from the intestines into the blood, and of course, less calcium in the blood. This signals PTH that there isn't enough calcium in the body, and activates osteoclasts to break down bone to take care of this disequilibrium. The increased phosphate in the body also causes secondary hyperparathyroidism, which also leads to the activation of osteoclasts. In the long run, this cycle can lead to osteomalacia. Also if the calcium x phosphate product is >55, you would want to consider treating the patient with calcimimetics, vitamin D analogs, lanthanum, etc. The whole spectrum of what happens is definitely more complicated than this, and this explanation serves as a summary :).

Infectious
Last week we had a review about sepsis and neutropenic fever. First of all SIRS (systemic inflammatory response syndrome) is defined as 2 out of the 4: fever of <38'C, tachypnea, tachycardia, leukocytosis/leukopenia. Sepsis is SIRS + infection. Severe sepsis is sepsis + end organ dysfunction (altered mental status, liver failure, intubation, heart dysfunction, etc.). Septic shock is severe sepsis + hypotension DESPITE adequate fluid resuscitation. Antibiotics and vasopressors would be given until the Mean Arterial Pressure > 65 (MAP = 1/3SBP + 2/3DBP). Neutropenic fever has to meet two definitions - neutropenia (ANC < 500), and fever (temperature of 101'F once or 100.4'F sustained).

Imaging
During rounds, I constantly hear about MRI/CT/Ultra sound, and wanted to get a better idea of what each one has to offer. A CT shows fine slice images of the body, but it uses radiation (can also do spiral CT, which is a 3-D image). An MRI does not use radiation, and the pictures from this time of imaging are also very useful for diagnoses; however, no magnets or implanted medical devices can be in the vicinity of the scan. An ultra sound also doesn't use radiation, but it's not as clear for highly dense areas, such as big bones, in the body.

Recommendations
Friday (7/1): Patient came in with a GI bleed, and was given pantoprazole 80mg IV for gastric protection. The attending looked right at me and asked what, if anything, the patient should be on as an out patient. My recommendation was omeprazole 40mg BID (this patient's situation was serious regarding GI bleeding and ulcers). This was the dose that was ordered.

Tuesday (7/5): Patient came in with unstable angina, and I recommended that the patient's ibuprofen be D/C'd due to the risk of vasospasm, and also to start nitroglycerin sublingual PRN for chest pain.

Anyway, my next management conference is coming up on July 22. I'm looking for a topic...something that would be useful for pharmacists to know about drug therapy for any disease really (well, preferably a topic that would pertain to the older VA population), and something with a couple legit journal articles to analyze. Any suggestions would be appreciated :)!