Today was the first day of rotations...first part of the day was more orientation, and needless to say, pretty uneventful. The pace picked up at 1:00 pm, when I met with my preceptor. I listened to the resident presenting about 15 patient cases, and before I knew it, it was time to go home.
I've been assigned 3 patients to begin with, and as time goes on and I become more comfortable suggesting ways to optimize drug therapy, I'll probably be assigned a few more.
I learned a few things today though!
Infectious
When a patient is on IV antibiotics, and will likely need them at discharge, look up the oral equivalents to any IV-only antibiotics. This keeps you ahead of the game. Also, the trough drug concentrations of Vancomycin are measured, and the therapeutic range is between 10-20mg/dL. However, the range is 15-20mg/dL for complicated skin infections, bone infections, bacterial meningitis [thanks Edric] bacteremia, and hospital acquired pneumonia.
Renal
If there's a 30% or a 0.5 increase of serum creatinine in a patient, then that's defined as Acute Kidney Injury (divided into prerenal -usually dehydration issues-, intrinsic -actual damage due to medications-, and post renal, where there is obstruction). The different categories can be defined by the BUN:SCr ratio.
Heart
If a patient undergoes CABG, he/she is at risk for Afib shortly after the surgery. If <48 hours, then warfarin is used for cardioconverstion. If >48hours, then chemical conversion with amiodarone (or similar drugs) is done. (I need to double check on this one though...not sure if I write it down correctly). Also, for a CHAD2 score, being >75y/o is the biggest risk. Lastly, when a patient is post MI, troponin levels tend to rise after 3-12 hours. 3 consecutive negative troponin lab results must be done in order to discharge the patient. Need to be careful, because troponin levels don't increase right after the MI, and may take some time.
That's about it for today. I go on rounds tomorrow, so more to come...!
This comment has been removed by the author.
ReplyDelete^Woops, meant to edit it.
ReplyDeleteAnyways, tack on bone infection and bacterial meningitis and you got a solid list of infections that "require" a trough of 15-10 :D
Sounds fun though! Where are you situated?
I've been taught 15-20 on ICU patients too!
ReplyDeleteNice work Neha
After a patient goes through a CABG, what are the medications they will (typically) be prescribed for A-fib?
ReplyDeleteIf a patient is allergic to vancomycin OR cannot tolerate it because of Red Man Syndrome, what would be your next drug of choice for the above mentioned conditions?
Also, when would you consider the transition to dapto? What would be the appropriate dosing? Why can you not use daptomycin for pneumonia?
ReplyDeleteL:
ReplyDelete1. Linezolid or daptomycin would work. Are there any others that I'm missing?
2. If the patient couldn't tolerate vanco d/t RMS, then the patient could be given IV benadryl and the infusion rate of vanco could be slowed down (this could be considered first, since daptomycin is about 10x as expensive as vanco). If this doesn't work, then IV daptomycin could be started.
3. For skin infections, 4mg/kg q24 hours x 7-14 days. For staph bacteremia, 6mg/kg IV 124 hours x 2-6 weeks. If CrCl <30 or on dialysis, then give same dose q48 hours.
4. Daptomycin can't be used for lung infections, since pulmonary surfactants inactive the drug.
Thanks for asking all these useful follow up questions, and sorry about the delay in answering them!