Critical Care and Emergency Medicine Pharmacy Guidelines

[Sparda29]

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Anyone got some good websites for a pharmacist to brush up on critical care and emergency med topics? I've been working overnights inpatient the last 3 months, and I've been noticing these topics are the main things that the residents call down to ask about. Eg: recently learned that giving Calcium won't do much if the Magnesium is also low.

 

[samven582]

Shouldn't your hospital have protocols? I recommend this website pharmacyjoe.com

 

[RxEvileye]

ASHP:

Page Not Found

www.ashp.org

EMCrit:

EMCrit Project

We are obsessed with Emergency Department (ED) Critical Care. A blog & podcast for medical education on ED Intensive Care, Trauma, and Resuscitation.

emcrit.org

Consider getting the ACCP Pharmacotherapy or Critical Care Preparatory Review and Recertification course PDFs.

 

[PharmDBro2017]

Anyone got some good websites for a pharmacist to brush up on critical care and emergency med topics? I've been working overnights inpatient the last 3 months, and I've been noticing these topics are the main things that the residents call down to ask about. Eg: recently learned that giving Calcium won't do much if the Magnesium is also low.

If mag and potassium are both low, you have to replete magnesium before potassium.

edit: also recommend pharmacyjoe.com and his podcast "the elective rotation" is solid.


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[gwarm01]

Let's keep the clinical tips coming in this thread. I'm four years out of practice and wanting to hone the blade.

 

[Sparda29]

If mag and potassium are both low, you have to replete magnesium before potassium.

edit: also recommend pharmacyjoe.com and his podcast "the elective rotation" is solid.


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I know that one also.

It's funny how that the school didn't even spend one day talking about electrolytes. They offered a rotation in critical care as an elective but the professor/preceptor in charge was known to be a very demanding lady so people avoided it.

 

[PharmDBro2017]

I know that one also.

It's funny how that the school didn't even spend one day talking about electrolytes. They offered a rotation in critical care as an elective but the professor/preceptor in charge was known to be a very demanding lady so people avoided it.

That's odd. It typically is one of the cornerstone topics, like one of your first real lectures in pharmacotherapy... at least it was at my school.

Same type of professor at my school (and ICU). That's why I picked her... you learn from the tough ones.

 

[sakigt]

I listen to pharmacy joe, emcrit, em basic, Rosalind franklin university, er cast, em cases

But nowadays I mostly only using the $300ish a year EM:Rap. I get the hospital I work for pay for it. Its like about 10 hours a month of stuff.

I did BCCCCCCCCCCCCCCCCCCCCP and that was good as well

 

[owlegrad]

Are you sure your school didn't talk about electrolytes or maybe you just skipped that block?

Like at no point did you learn about Klor-Con? Or they somehow managed to teach it without mentioning it is an electrolyte?

 

[PharmDBro2017]

Are you sure your school didn't talk about electrolytes or maybe you just skipped that block?

Like at no point did you learn about Klor-Con? Or they somehow managed to teach it without mentioning it is an electrolyte?

I chuckled reading this.

Anyway... I hope y'all know not to push KCl

 

[Sparda29]

Are you sure your school didn't talk about electrolytes or maybe you just skipped that block?

Like at no point did you learn about Klor-Con? Or they somehow managed to teach it without mentioning it is an electrolyte?

Yeah, we learned about Klor-Con as a potassium supplement.





However, we didn't get a lecture like this that explained the relationship between how a bag of 10 meq IV KCL should increase the potassium blood level by 0.1. I don't know if it was because my class was the first class and we were the guinea pigs but this is the important stuff we should have been taught rather than wasting our time with Biostatistics and epidemiology and public health. In the last 7 years, I have never had to analyze a study or find a p value or explain that a study is statistically insignificant or clinically significant etc.

 

[KeikoTanaka]

If you're interested in Electrolytes and stuff like that, as a Medical Student, we're learning about it a ton right now.

I would recommend getting an Internal Medicine book about Nephrology.

When it comes to electrolytes, yes, this can be an "emergent issue" but it is the ultimate responsibility of the kidney, and Internal Medicine is a Segway into a Nephrology fellowship.

So even though not an "Emergency Med" book per se, I think you would do well finding nephrology literature for electrolytes.

 

[owlegrad]

Yeah, we learned about Klor-Con as a potassium supplement.





However, we didn't get a lecture like this that explained the relationship between how a bag of 10 meq IV KCL should increase the potassium blood level by 0.1. I don't know if it was because my class was the first class and we were the guinea pigs but this is the important stuff we should have been taught rather than wasting our time with Biostatistics and epidemiology and public health. In the last 7 years, I have never had to analyze a study or find a p value or explain that a study is statistically insignificant or clinically significant etc.

You don’t review primarily literature and critically evaluate using biostatistics to answer drug questions? What kind of pharmacist are you?!

 

[PharmDBro2017]

Yeah, we learned about Klor-Con as a potassium supplement.





However, we didn't get a lecture like this that explained the relationship between how a bag of 10 meq IV KCL should increase the potassium blood level by 0.1. I don't know if it was because my class was the first class and we were the guinea pigs but this is the important stuff we should have been taught rather than wasting our time with Biostatistics and epidemiology and public health. In the last 7 years, I have never had to analyze a study or find a p value or explain that a study is statistically insignificant or clinically significant etc.

It is very common knowledge that 10mEq will roughly raise K level 0.1, depending on how low the patient is. If patients K is at 2.5, giving 100mEq is not likely to get them to 3.5. They will need more than the standard and it becomes more individualized. Again, get the Magnesium replacement in first before you give the KCl too.

 

[samven582]

Yeah, we learned about Klor-Con as a potassium supplement.





However, we didn't get a lecture like this that explained the relationship between how a bag of 10 meq IV KCL should increase the potassium blood level by 0.1. I don't know if it was because my class was the first class and we were the guinea pigs but this is the important stuff we should have been taught rather than wasting our time with Biostatistics and epidemiology and public health. In the last 7 years, I have never had to analyze a study or find a p value or explain that a study is statistically insignificant or clinically significant etc.

As someone who also when to TCOP, I can definitely say our school failed us. During the first two years, I can't remember if critical care was thought to us.

 

[Sparda29]

If you're interested in Electrolytes and stuff like that, as a Medical Student, we're learning about it a ton right now.

I would recommend getting an Internal Medicine book about Nephrology.

When it comes to electrolytes, yes, this can be an "emergent issue" but it is the ultimate responsibility of the kidney, and Internal Medicine is a Segway into a Nephrology fellowship.

So even though not an "Emergency Med" book per se, I think you would do well finding nephrology literature for electrolytes.

I ended up buying the Washington Manual for Medical Therapeutics and Pharmacy Joes book on Medical Emergencies.

 

[Sparda29]

You don’t review primarily literature and critically evaluate using biostatistics to answer drug questions? What kind of pharmacist are you?!

The kind that uses GlobalRph and LexiComp.

 

[Dred Pirate]

EMRA for abx is a great quick and easy reference

 

[drock008]

VCCR podcasts.


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[Xarelto-10]

Most of electrolyte replacement is done with standing protocols. Most of the replacement occurs right around the 4-6 AM.

what I found challenging at times was RN’s asking all sorts of lytes in one bag. One can find compatibility report for some but others it’s unknown. The pressure from Nurses is just tremendous when you feel you have to split it into two bags or so bc they want to be done with one hang.

anybody encountered compatibility dilemma and how do you go about it?

 

[TimeZero]

If you're interested in Electrolytes and stuff like that, as a Medical Student, we're learning about it a ton right now.

I would recommend getting an Internal Medicine book about Nephrology.

When it comes to electrolytes, yes, this can be an "emergent issue" but it is the ultimate responsibility of the kidney, and Internal Medicine is a Segway into a Nephrology fellowship.

So even though not an "Emergency Med" book per se, I think you would do well finding nephrology literature for electrolytes.

'The dumbest kidney is smarter than the smartest doctor'. Something I learned early on and has served me well along the way.

As far as electronic EM and CC sources, I usually peruse EM PharmD and EMCrit Project (EM, CC and tox content). Both provide quick, easy to read write-ups. The IBCC (internet book of cirtical care) chapters available via emcrit provide further depth if that's what you are looking for.

 

[Carboxide]

Most of electrolyte replacement is done with standing protocols. Most of the replacement occurs right around the 4-6 AM.

what I found challenging at times was RN’s asking all sorts of lytes in one bag. One can find compatibility report for some but others it’s unknown. The pressure from Nurses is just tremendous when you feel you have to split it into two bags or so bc they want to be done with one hang.

anybody encountered compatibility dilemma and how do you go about it?

I get these questions all the time and honestly I don't feel pressure about it...it is what it is, if there's no data then we don't play. It's just a fact.

 

[Carboxide]

Yeah, we learned about Klor-Con as a potassium supplement.





However, we didn't get a lecture like this that explained the relationship between how a bag of 10 meq IV KCL should increase the potassium blood level by 0.1. I don't know if it was because my class was the first class and we were the guinea pigs but this is the important stuff we should have been taught rather than wasting our time with Biostatistics and epidemiology and public health. In the last 7 years, I have never had to analyze a study or find a p value or explain that a study is statistically insignificant or clinically significant etc.

You don't analyze studies for clinical and statistical significance? How do you decide if you should be incorporating a new study into your practice? Or do you just not read literature?

 

[samven582]

You don't analyze studies for clinical and statistical significance? How do you decide if you should be incorporating a new study into your practice? Or do you just not read literature?

I'm wondering the same as well

 

[Dred Pirate]

Most of electrolyte replacement is done with standing protocols. Most of the replacement occurs right around the 4-6 AM.

what I found challenging at times was RN’s asking all sorts of lytes in one bag. One can find compatibility report for some but others it’s unknown. The pressure from Nurses is just tremendous when you feel you have to split it into two bags or so bc they want to be done with one hang.

anybody encountered compatibility dilemma and how do you go about it?

I have processed thousands of electrolyte replacement orders in my life and I have NEVER had a RN ask me to put it all in one bag. Does your hospital not have a set protocol and the RN just orders it through the EMR (and you verify the electrolyte level, central/peripheral line?)

In EPIC it literally takes one click (the K/mag/cal/phos level pops up on the order, and the verbage of what level range they selected is all right there). If I was asked it manipulate the order it would take several minutes at best vs 5 seconds.

 

[Sparda29]

You don't analyze studies for clinical and statistical significance? How do you decide if you should be incorporating a new study into your practice? Or do you just not read literature?

Occasionally when I can't find info in the textbooks or databases, but still, we didn't need 3 semesters to learn that stuff. Learning how to analyze a study shouldn't require more than 2-4 lectures.

 

[Xarelto-10]

I have processed thousands of electrolyte replacement orders in my life and I have NEVER had a RN ask me to put it all in one bag. Does your hospital not have a set protocol and the RN just orders it through the EMR (and you verify the electrolyte level, central/peripheral line?)

In EPIC it literally takes one click (the K/mag/cal/phos level pops up on the order, and the verbage of what level range they selected is all right there). If I was asked it manipulate the order it would take several minutes at best vs 5 seconds.

Well I said “at times” not, always. I think you didn’t read what I wrote carefully. But say for instance MgSO4 4 GM/ Ca Gluc 2 GM/KCL 40 meq etc this is just an arbitrary one not an actual one. Sometimes I split t I’m two bags but you’ll be that “difficult” pharmacist 🙂

We use Meditech and they are just so spoiled they will pick mag so4 order and put on comment field whatever else they want added.

 

[BidingMyTime]

Well I said “at times” not, always. I think you didn’t read what I wrote carefully. But say for instance MgSO4 4 GM/ Ca Gluc 2 GM/KCL 40 meq etc this is just an arbitrary one not an actual one. Sometimes I split t I’m two bags but you’ll be that “difficult” pharmacist 🙂
We use Meditech and they are just so spoiled they will pick mag so4 order and put on comment field whatever else they want added.

Well, nurses do that because they don't know what is compatible, and they are hoping it will be compatible. But if it's not, tell them nothing says it's compatible, so it can't be done. Why would that make you the "difficult" pharmacist, surely your co-worker pharmacists aren't just willy-nilly mixing together anything nursing requests? That would be a receipe for disaster. If the nurse doesn't like it, then she can complain to her manager, who will then complain to your Director, and surely your Director would say that compromises in patient safety for nursing convenience can not be done.

 

[Dred Pirate]

Well I said “at times” not, always. I think you didn’t read what I wrote carefully. But say for instance MgSO4 4 GM/ Ca Gluc 2 GM/KCL 40 meq etc this is just an arbitrary one not an actual one. Sometimes I split t I’m two bags but you’ll be that “difficult” pharmacist 🙂

We use Meditech and they are just so spoiled they will pick mag so4 order and put on comment field whatever else they want added.

for us - each electrolyte goes in its own bag - simple enough - if it is compatible, they can y-site it

 

[lane one]

Well I said “at times” not, always. I think you didn’t read what I wrote carefully. But say for instance MgSO4 4 GM/ Ca Gluc 2 GM/KCL 40 meq etc this is just an arbitrary one not an actual one. Sometimes I split t I’m two bags but you’ll be that “difficult” pharmacist 🙂

We use Meditech and they are just so spoiled they will pick mag so4 order and put on comment field whatever else they want added.

This is just bad practice. No better than ordering PO levaquin and writing in the comments "please give IV".

 

[Xarelto-10]

This is just bad practice. No better than ordering PO levaquin and writing in the comments "please give IV".

Yep. Bad practice all the way.
I have come to learn the hard way just to ignore that type of stuff and move on.

 

[KidPharmD]

'The dumbest kidney is smarter than the smartest doctor'. Something I learned early on and has served me well along the way.

As far as electronic EM and CC sources, I usually peruse EM PharmD and EMCrit Project (EM, CC and tox content). Both provide quick, easy to read write-ups. The IBCC (internet book of cirtical care) chapters available via emcrit provide further depth if that's what you are looking for.

I'm sure that quote makes sense somewhere, but I think my 7 year old is smarter than the average premie's kidneys.

 

[TimeZero]

I'm sure that quote makes sense somewhere, but I think my 7 year old is smarter than the average premie's kidneys.

Context is important. Obviously this wouldn't apply to dialysis patients or any other adult patient with advanced kidney disease. In a reasonably healthy patient, the body will take care of itself.

PulmCrit - Correlation confounded by timing: One reason we believe bad therapies are awesome

example 1: anti-emetics Let’s get started with a RCT comparing droperidol versus ondansetron for the treatment of nausea in the emergency department.

emcrit.org

I'll take your word for it when it comes to premies, I don't fux with pediatrics.