Clinical Question of the Day Pilot Thread 4/18-4/19

rxlea

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This thread is for teaching/learning. Preceptors, pharmacists, or other practitioners should feel free to post clinical questions/cases for us students to learn from. It will give us practical knowledge, promote critical thinking, and help preceptors/pharmacists perfect questioning/teaching.

:love:We appreciate it!
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Rule #1 - No fighting/arguing!
Rule #2 - No talking about CVS, PBMs, Medicaid babies, "parasites", the job market, diploma mills, or baggies of cocaine unless it DIRECTLY relates to the clinical question/case!
Rule #3 - No fighting/arguing!
 

Its Z

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How important is Vancomycin loading dose in bacteremia? Ever see orders like Vanco 1gram now and pharmacy to dose?

Look up a recent article in CID.. Ravina Kullar investigator. She presented her study at ICACC in 2009...it finally published.
 
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Its Z

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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..
 

Its Z

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The three different types of pneumonia, community, hospital, ventilator???

Why don't you go and read the entire core measure pneumonia document instead making wild guesses. If you're going to do something do it right. That means learn the stuff instead of half ass doing it taking the path of least resistance.
 

Its Z

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The three different types of pneumonia, community, hospital, ventilator???

IV quinolones for hospital acquired + ceftriaxone or carbapenems.

Add on aztreonam if it's Pseudomonas.

Sigh...
 

Its Z

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Once you're done reading the core measure doc....go read the idsa pneumonia guidelines.
 

habeansha

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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..

not complete but better then above, i think?

outpatient, non-ICU, and ICU (cover pseudomonas)

outpatient is typically respiratory FQ PO maybe azithromycin too PO
non-ICU: cephalosporin (ceftriaxone) + FQ (Cipro or levaquin) IV or Azithromycin (i think it can be IV or PO)
ICU: Rocephin doesnt cover Pseudomonas so Ceftaz or cefipime plus a FQ and i can't remember if a third drug is optional or not, but it could be a AMG. aztreonam is an option for PCN allergic

i did CAP chart reviews during my hospital rotation and that was a good learning experience. I better go brush up
 
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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..

Jesus Christ,:laugh: my preceptor just had me look it up today - I have a pt in ICU with bacteremia and VAP, I spend at least an hour looking it up and typing it up, making that precise table you describe. Even on SDN I can't escape my 12-13 hr rotation days. :scared: :laugh: Loving it ! :smuggrin: :love:

Here's a quickie, as a tease for HAP/VAP only - since I just cropped the image in paint literally mins ago:

HAP2.jpg



HAP.jpg


And here is a picture of my cuddly furry pet as a bonus for people doing CAP:

08b660ee.jpg
 

PharmDstudent

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Another worthless ID thread where pimping gets nowhere... :rolleyes:

Jesus Christ,:laugh: my preceptor just had me look it up today - I have a pt in ICU with bacteremia and VAP, I spend at least an hour looking it up and typing it up, making that precise table you describe. Even on SDN I can't escape my 12-13 hr rotation days. :scared: :laugh: Loving it ! :smuggrin: :love:
Thank you for posting real information and not wasting everyone's time with fake posts :)rolleyes::rolleyes::rolleyes:) that are just meant to show how great you are.
 

rxlea

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Another worthless ID thread where pimping gets nowhere... :rolleyes:

Thank you for posting real information and not wasting everyone's time with fake posts :)rolleyes::rolleyes::rolleyes:) that are just meant to show how great you are.

If you don't like ID give us something else.
Thanks for the tables chebs.

Drugs of choice at my site are Zosyn, vanco, and levo.
 

TemSirolimus

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Another worthless ID thread where pimping gets nowhere... :rolleyes:

Thank you for posting real information and not wasting everyone's time with fake posts :)rolleyes::rolleyes::rolleyes:) that are just meant to show how great you are.


Did this person read the title of the thread?

I just realized I dont deal with waay too complicated chit that MD consult + Facts and comparisons cant answer within seconds if needed for reference. But again, this is LTC.
 

PharmDstudent

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If you don't like ID give us something else.
Thanks for the tables chebs.

Drugs of choice at my site are Zosyn, vanco, and levo.
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.

Did this person read the title of the thread?

I just realized I dont deal with waay too complicated chit that MD consult + Facts and comparisons cant answer within seconds if needed for reference. But again, this is LTC.
Yes. Did you read the title of the thread Mr. Wishy-washy?

You're right, though. Pharmacy is not that complicated...
 

Its Z

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Jesus Christ,:laugh: my preceptor just had me look it up today - I have a pt in ICU with bacteremia and VAP, I spend at least an hour looking it up and typing it up, making that precise table you describe. Even on SDN I can't escape my 12-13 hr rotation days. :scared: :laugh: Loving it ! :smuggrin: :love:

Here's a quickie, as a tease for HAP/VAP only - since I just cropped the image in paint literally mins ago:

HAP2.jpg



HAP.jpg


And here is a picture of my cuddly furry pet as a bonus for people doing CAP:

08b660ee.jpg



Do you bite your nails?
 

Its Z

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not complete but better then above, i think?

outpatient, non-ICU, and ICU (cover pseudomonas)

outpatient is typically respiratory FQ PO maybe azithromycin too PO
non-ICU: cephalosporin (ceftriaxone) + FQ (Cipro or levaquin) IV or Azithromycin (i think it can be IV or PO)
ICU: Rocephin doesnt cover Pseudomonas so Ceftaz or cefipime plus a FQ and i can't remember if a third drug is optional or not, but it could be a AMG. aztreonam is an option for PCN allergic

i did CAP chart reviews during my hospital rotation and that was a good learning experience. I better go brush up

You came close but your categories are not quite correct.
 

Its Z

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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.
 

Its Z

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in my ADHD state....lets switch gears...

Heparin IV infusion, what are the loading doses for a-fib, acs, vte treatment, and acs patient with thrombolytic administration and what infusion rate for each. How often does the hospital run the heparin response curve and is it protamine or anti-Xa assay and what is the therapeutic range? And most important does your institution have a protocol that accurately include the dosing and titration range based on the latest recommendation?
 
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Its Z

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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.
 

Its Z

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How reverse bleeding resulting from pradaxa, effient, and xarelto?
 

Its Z

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I don't know...you want me to start a "clinical question of the day" thread?
 

rxlea

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I don't know...you want me to start a "clinical question of the day" thread?

That would be awesome! I can change the title of this thread.
 

UES Girl

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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.

Yes. Did you read the title of the thread Mr. Wishy-washy?

You're right, though. Pharmacy is not that complicated...

Do you bite your nails?

Yeah school stress and constant feeling of not being good enough - during summers I don't bite them:)
 

psychoandy

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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.
 

rxlea

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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.

precedex...fast onset/quick recovery.

But expensive.
 

rxlea

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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.

What's my underlying disease state? And what medications is the patient on?

I'll handle each of your questions one at a time when I have time between classes :)

For hypervolemic hyponatremia, you want to move sodium out of the cell and free water in- potassium administration.

You don't want to correct the sodium too fast because of osmotic demyelination. Salt can make edema worse.

For euvolemic, I'm going to say 1/2 NS
 

gotdrugs

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precedex...fast onset/quick recovery.

But expensive.

Define fast onset. W/ or w/o bolus? What's the very real risk of giving the bolus and why many (most) practitioners won't give a bolus anymore.
 

gotdrugs

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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.

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.
 
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gotdrugs

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What's my underlying disease state? And what medications is the patient on?

I'll handle each of your questions one at a time when I have time between classes :)

For hypervolemic hyponatremia, you want to move sodium out of the cell and free water in- potassium administration.

You don't want to correct the sodium too fast because of osmotic demyelination. Salt can make edema worse.

For euvolemic, I'm going to say 1/2 NS

I think Z is alluding to one drug (actually two - one po and one IV)

Or I'm assuming incorrectly.
 

rxlea

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I think Z is alluding to one drug (actually two - one po and one IV)

Or I'm assuming incorrectly.

Furosemide 1mg/kg IV

Tolvaptan 15mg orally daily (although I have never seen this)
 

Sparda29

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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.

Or not taught at all. I was googling core measures for pneumonia last night. Found a bunch of different links from different hospitals. I was thinking this document is something like JNC7?

All I found for the 6 Core Measures were:

Oxygenation Assessment
Pneumococcal Vaccination if needed
Abx within 6 hours of arrival
% of ppl given the most appropriate initial abx
Blood cultures for pneumonia patients admitted thru ED
adult smoking cessation teaching

3 types of pneumonia? What else is there other than community acquired, hospital acquired, and ventilator associated?
 

gotdrugs

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3 types of pneumonia? What else is there other than community acquired, hospital acquired, and ventilator associated?

Please note Z never stated "3 types" of pneumonia if that helps you out.


(FYI, even if he did, you are still off-base)
 

rxlea

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Again, if my assumption is correct you are half-right.

Doesn't it depend on the underlying disorder though?

And the severity?

I'll look it up but I know we rarely use hypertonic

...

Damn phone.


we hardly use Conivaptan
 

gotdrugs

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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.

Acute? Chronic? Symptomatic?

Defines the plan.
 

gotdrugs

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Doesn't it depend on the underlying disorder though?

And the severity?

I'll look it up but I know we rarely use hypertonic

...

Damn phone.


we hardly use Conivaptan

to answer your two questions

1) Maybe, but more likely depends on #2

2) Yes
 

gotdrugs

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we hardly use Conivaptan

We never use it, but it's worthwhile to know what's out there that you don't use that way you can make sure some doc who had a lunch doesn't use it inappropriately (I know you are a student, just giving advice for when you are no longer a student)
 

gotdrugs

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Thanks. I need some specifics here! lol

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.
 

habeansha

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How reverse bleeding resulting from pradaxa, effient, and xarelto?

pradaxa is supportitive, FFP and clotting factors. ~50% dialyzable

xarelto i believe is the same, but its not dialyzable, theres also a small study using PCC that worked in healthy males but that isn't available in the US

im gonna have to look up effient
 

habeansha

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Yep, but in the real world clinical setting, what is the problem with this method to reverse?

getting the patient set up for dialysis would take way too long if they are not already on dialysis
 

Carboxide

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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.

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.
 

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Solved our high risk pneumococcal vaccine CMS problem...pts offered vaccines increased from 40% to 95%...
 
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