Some MONA(BS) Stat, Please!

Although I was very disappointed that my ID rotation (#3) got canceled, I’m pretty happy with the amount of ID information I’m getting everyday. It’s mostly pneumonia and UTI, but hey, if it’s common infections, might as well know the therapy like the back of my hand.

Anyway, about the medicine team – I think they’re all awesome. The attending is great, and is very receptive to suggestions my preceptor has regarding drug therapy. For example, one of the medical interns had a patient who developed tachycardia for no apparent reason. The pharmacist noticed that one of the patient’s outpatient meds was carvedilol, and was D/C’d in the hospital. He suggested starting up a beta blocker again to try and control the tachycardia, and metoprolol was ordered for the patient :).

As for things I learned in the last two days that I think are actually going to stick…

Anticoagulation

DVT prophylaxis is always assessed for every patient, and is important in the acute setting. Enoxaparin is much more expensive than UFH, so UFH is more commonly used (although more inconvenient, given the TID dosing). The UFH DVT prophylaxis dose is 5000U SQ TID. The enoxaparin dose is commonly 40mg SQ once daily, can go up to 30mg SQ BID, and adjusted for renal dysfunction (CrCl<30ml/min) at 30mg SQ once daily. Scenario: say a patient takes warfarin regularly, gets admitted to the hospital, and  has a supratherapeutic INR (~5.0), causing the warfarin to be D/C’d. Well, what if the INR suddenly drops to 1.8? At this point, we'd need to restart the warfarin, but it takes a few days to work…soo BRIDING therapy with heparin comes into play! I remember learning this last month in kinetics, but now that it's clinically relevant, it should stick ;). Also on the topic of INR…the following antibiotics will almost always raise INR when given with warfarin: Bactrim, and Azithromycin, Metronidazole. Last tidbit about INR – if it gets too high, it can be reversed with Vitamin K or fresh plasma (the latter is quicker, but also doesn’t last very long).

Heart

If someone comes into the hospital with chest pain, what do you give them? MONA(BS)!! So we learned MONAB in school. Now there’s also the “S” component, which apparently has shown to be beneficial. The acronym stands for Morphine, Oxygen, Nitrogen, Aspirin (+/-clopidogrel), Beta Blocker, Statin. The morphine isn’t only for pain – it can actually improve oxygenation to the heart…I believe it’s by decreasing the demand for oxygen. Oxygen is given for obvious reasons. Nitro dilates the vessels to get more blood through, and ASA to thin the blood a little bit. BB is helpful in decreasing the demand of oxygen, and I’ll look into exactly why statins are beneficial. Also, all chest pain doesn’t have to do with the heart. If someone receives nitroglycerin, and the chest pain doesn’t improve, then it could be because of epigastric pain or extreme GERD as well.

Liver

What’s the relationship between a patient having ascites and receiving albumin? I had no idea until about 4:15pm today. So basically, if a patient is receiving a tap to remove the ascites, an oncotic agent such as hetastarch or albumin will be given to the patient so the fluid from the intravascular won’t get into the abdomen to replace the ascites fluid. If an oncotic agent isn’t given, there’s a chance for hypotension, since there will be less fluid in the intravascular, since it'll move to the abdomen. 

Lab Values

SAAG is the serum-ascites albumin gradient, and it helps determine the cause of ascites. SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid). If this value is >1.1g/dL, the ascites is likely due to portal hypertension. More specifically, if the value is >2.5, then it’s likely due to heart failure and if <2.5 (but still >1.1), then it’s likely due to cirrhosis. If <1.1, then the ascites is more associated with tuberculosis or various types of cancers.

That’s it for the last couple days. I promise I have been learning ID stuff, but I wanted to organize the bugs and drugs for pneumonia in my head before posting about it! 

And about rotations in general...not only my 3rd, but my 4th rotation was canceled as well...awesome! I got the 4th one replaced at Shea Health Care in Scottsdale, and working on getting a contract with a clinic in North Carolina for #3 :).