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Page 2
While he answers, what are your goals (for correction)? How to monitor? That's where you can play a big role, trust me, not only in tx choice but the entire course as the residents you are working with will likely have little clue on what should be done.
Or the attendings who are not sticklers to details.
It's not that I don't like ID, because I do. I call on doses that are wrong and watch what people are getting in retail. I've made suggestions on doses in the charts, too, and checked a million kidney functions. I just despise the attitude that people have on this forum that ID is some kind of superior knowledge or whatever, because it's really not.
Tremors associated with a diphenhydramine overdose in a 100 year old, and tremors with possible serotonin syndrome in a patient with major depression.
Pharmacy is not that complicated...
Forget ID. With the current shortage of IV benzos + crazy ICU admits who are still bucking the vent on propofol drip + midazolam boluses, why don't we talk about nontraditional/2nd line sedation strategies? What can you use outside of propofol and benzos? A pros/cons list for each agent would be even better.
Yep, but in the real world clinical setting, what is the problem with this method to reverse?
What you really need to ask is why are they crazy and bucking the vent. What's the patient's background? Why are they on the vent? What were they on prior to admit (both pharmacy drugs and street pharmacy drugs)? Wow, are they in pain - you should read data and recommendations about the use of opioids/pain mgt in this situation? At what point is the "still bucking the vent?" - i.e. a few hours or a few days later.
Ah - this one I know Core measure score indicates basically the quality of your care. I believe it measures readmittance for the same condition within 30 days of discharge. If the number of readmits is too high, then you can receive lower reimbursements - like 50% normal costs. It is supposed to disincentivize admittance and incentivize providing good care that doesn't result in readmissions. The value based purchasing is the practical method of this - how much they pay depends on the CMS.
In real life, this makes sense but has some problems - big hospitals that focus on very ill patients as opposed to community hospitals that primarily treat relatively simple conditions will have higher readmittance rates, and although they supposedly take this into account it doesn't always help enough to even out the difference.
Start dialyzing a bleeding patient??
alcoholic...
getting the patient set up for dialysis would take way too long if they are not already on dialysis
This is exactly what I'm talking about. You act like how you practice is the only right way. What's the point in trying to intimidate people on SDN? It's not a game show. Worthless.ID has nothing to do with superior knowledge or however you put it. It is however typically the highest cost classification medication for a non-oncology service. Also, because core measure compliance (which you have no experience with since LTACs and retail don't participate) with SCIP and Pneumonia are tied to CMS reimbursement, it's a very important component of healthcare and pharmacy practice. Your opinion of foo fooing on ID is really laughable. If you have nothing to contribute to this topic, then simply do not reply.
I suppose it could be. I mean... it's what I came across while working and had to figure out - very straight-forward practice. *note sarcasm*Is that some sort of a superior knowledge??
Seriously? Every day I realize how much I don't know about how things are made, too. And whenever I want to learn about it, I get to watch it on Youtube.Pharmacy practice is complicated. It involves clinical, operational, regulatory, quality, & financial challenges. It's complicated. Everyday I realize how much more I need to learn.
Still no correct answer to 3 different criteria of pneumonia and drug selections.
I hope that's what you're asking
HAP - occurs 48 hr or greater after admission
VAP - arises 48-72 hr after intubation
HCAP - acute care for 2 or more days w/in 90 days or LTC or abx within 30 days
if HAP, VAP, HCAP suspected --> late onset or MDR risk --> broad spectrum coverage --> zosyn (4.5g q6) , vanco (20mg/kg q12), levo (750mg qdaily) is reasonable
I hope that's what you're asking
This is exactly what I'm talking about. You act like how you practice is the only right way. What's the point in trying to intimidate people on SDN? It's not a game show. Worthless.
I suppose it could be. I mean... it's what I came across while working and had to figure out - very straight-forward practice. *note sarcasm*
It wasn't some kind of Scrabble game.
Seriously? Every day I realize how much I don't know about how things are made, too. And whenever I want to learn about it, I get to watch it on Youtube.
[YOUTUBE]http://www.youtube.com/watch?v=WB3st6SQnsk&feature=related[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=WQPT_FMQKV8[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=C4EmLvzmTHA&feature=related[/YOUTUBE]
**My whole point in trying to knock this type of intimidating style of learning on SDN is to show that you don't need to be an expert to make a difference, contrary to what SDN seems to portray in regards to ID. I think you need to be an expert to manage full-blown AIDS, since genotype and phenotype testing are not available in most settings, but not to question Bactrim DS BID x 3 days for UTI, Macrobid 500mg BID x 7 days, or Levaquin 500mg TID x 7 days, etc. which will show up in actual practice. Just reference your Drug Information Handbook **
But until the superiority complex associated with ID is no more, it will be just another barrier to learning and patient care.
Have you read the core measure document?
Ask and you shall receive.
Give a treatment option for hyper and euvolemic hyponatremia and why not salt tabs or concentrated saline. Provide the moa. How much does the treatment cost per day. Drug cost.
In which patients is stress ulcer prophylaxis actually indicated? Our medical interns can never get this right.
Ask and you shall receive.
Give a treatment option for hyper and euvolemic hyponatremia and why not salt tabs or concentrated saline. Provide the moa. How much does the treatment cost per day. Drug cost.
QUESTION FOR 4/19
In which patients is stress ulcer prophylaxis actually indicated? Our medical interns can never get this right.
Demeclocycline: induces nephrogenic diabetes insipidus -> secrete diluted urine. Couldnt find cost on lexi. Unlabeled use for euvolemic hyponatremia caused by SIADH.
Tolvaptan: vasopressin (ADH) antagonist -> urinate more. Couldnt find cost on lexi. For euvolemic/hypervolemic hyponatremia.
IV would be furosemide.
Why not salt tabs/NS: central pontine myelinolysis with rapid correction.
I read the guidelines the other night to curb my insomnia but, as a friend pointed out, it was a page turner. So, maybe not? I will go back and look for the "core measurement" document specifically.
EDIT: found it. answer to follow
(PN-6) Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
-Non ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg PO qdaily x3days
-ICU Patient: ceftriaxone 1g IV q24 + azithromycin 500mg IV q24 or zosyn 4.5g q6
Zosyn 4.5g q6 + levofloxacin 750mg IV q24 (if pseudomonal risk)
Core Measure Pneumonia PN6 refers to antibiotic selection.
Tell me the 3 different Criteria in pneumonia categories and what antibiotics are acceptable for each. Bonus.. dosing of antibiotics..
So I guess core measures (clinical quality measures) aren't very well taught in school?
To expand upon this, why is core measure score important what does value based purchasing mean to hospitals and health systems? It can make or break a hospital. This is huge.
1) Non-ICU:
[Beta-lactam (ceftriaxone, cefotaxime, amp/sulbactam, ertapenem) + (Macrolide OR doxycycline)] OR Respiratory FQ
2) ICU:
Beta-lactam (same as above) + (Macrolide IV or Respiratory FQ IV) OR (Respiratory FQ + Aztreonam) if pen allergic OR tigecycline
3) Pseud risk documented:
Antipseud beta-lactam (Cefepime, imipenem, meropenem, doripenem, pip/tazo) + Antipseud quinolone (IV if ICU)
OR
Antipseud beta-lactam + AG + (Respiratory FQ OR Macrolide [IV if ICU])
OR
Aztreonam + Respiratory FQ + AG (may omit if renal insufficiency documented AND using levofloxacin)
At my shop this equals:
Non-ICU: Ceftriaxone + doxy OR Moxifloxacin
ICU: Ceftriaxone + Moxifloxacin
Pseud: Zosyn + Cipro
All within 24 hours of first healthcare contact. We've used tigecycline a few times (I hate CMS sometimes)...and getting actual CMS-friendly Pseud risk documented is tougher than it seems.
$$$$$$$$$$$ - and cutthroat money at that. Can win big, can lose big, but it's zero-sum. Some hospitals stand to lose a lot more than they can gain. Gotta meet those metrics!
Nice...but about 70%. But you're getting hot.
I didn't know you wanted me to copy and paste the whole thing
And here I picked my own little regimen.
I don't want copy and paste but you left out pseudomonas risk category
And some say residency is useless. Thank you for the answer.. good work but ertapenem and tigecycline really? Your institution really has those drugs on CAP orders?
Not bad....but I like levofloxacin. 750mg and vancomycin 25mg/kg loading dose.
Why tigecycline for pseudomonas risk? It's not as effective against pseudomonas.
We don't load vanco! All dosing is based on a hospital nomogram targeting a 10-15 trough for all indications. I wasn't a believer at first, but I think the literature that has come out in the last year, year and a half really fails to support higher troughs at this point.
fluid restriction, vaptans
I had Zosyn and levo 750 for pseudomonas
...
But now I have that document as a pdf Hehe
Hired!
For pneumonia, evidence is weak I agree. But this has a lot to do with Zyvox funded studies.
However, for bacteremia, there's a nice study done at Wayne State recently published in CID where early high trough resulted in a better outcome. R Kullar is one of the primary investigator. It published this year.
But the answer isn't completely right.
I guess you have settled for "good enough" in your old age?
I saw that one, but I'm still not convinced. See Brown J, AAC 2012;56(2):634-8. I think MRSA-vanc troughs are one of those grey areas that are never going to go away. Some people are firmly on the less vanc side, others are on the more vanc side. At this point, you can make a very reasonable argument in either direction.
What it really comes down to is the same reason we don't use linezolid up front for suspected MRSA pneumonia - it benefits the people who actually have the infection they're treating, but there is no good way to empirically figure out who actually has MRSA pneumonia, bacteremia, etc. I believe the benefits of more aggressive dosing in the few patients who actually have true infections are outweighed by the risks to those who never had it. Perhaps as RT-PCR identification picks up, the picture will get clearer, but I'm not hopeful.
ETA: This doesn't account for the people who need vanc for one reason or another (Enterococcus, PCN-reistant S. pneumo, CoNS) yet still get dosed at 15-20. That's one of the biggest problems - as we push for MRSA trough targets, people forget that there is absolutely no data for, yet real harm associated with, aggressive dosing in non-MRSA infections.
Let me think about it.