More clinical questions pt. 5

[GravityBeetle]

1. Can Diamox ER caps be opened and sprinkled? They are not on ISMP list and package insert doesn't mention anything about not doing it.
2. Anyone ever used glucagon for someone choking on food? What dose? How effective is it? Any superior alternatives?
3. Does heparin have a max dose for treatment of PE/VTE? I know it does for cardiac dosing but can't find anything for this indication
4. Can you assume susceptibility to zosyn also confers susceptibility to augmentin and unasyn in enterobacteraciae with likely ampC resistance?

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[Rockinacoustic]

1). Unsure

2). Glucagon evidence for foreign body impaction is questionable: SGEM#169: Stuck in the Middle with Food (Glucagon for Esophageal Foreign Body Impaction)

3). Varies per institution- ours is 5,000 uni max bolus for VTE

4). Good question and I'm not 100% sure- I would say no as all three have different beta-lactamase inhibitors. However, our micro lab always reports amp/sulb and pip/tazo sensitivities on the same C&S though. There are instances where an organism will be amp/sulb resistant but amp/clav sensitive though as clavulanic acid is a more potent BL inhibitor than sulbactam

 

[rxkrafted]

1. If the package insert doesn't mention it, its safer to just keep the capsules intact and taken as it is. If it needs to be sprinkled, its better to switch to the immediate-release tabs and crush it.
2-4. See above post.

 

[PolarPop]

2. No but have seen SL nitro given while choking and it worked
4. The answer is no. AmpC organisms are intrinsically resistant to amox/clav and amp/sulbactam and they should always be reported resistant to these. Some labs hide the results and some report them always resistant. Here is the chart if you’re curious

 

[milipem]

Hi i would just like to ask something as well

In the event of a COPD patient having respiratory failure previously already on oral theophylline (10mg/kg/day elderly ex smoker)(however no levels ever taken before), has there ever been practice in giving a loading dose of aminophylline without any levels taken or should infusion maintenance dose only be given in such acute exacerbation case?

 

[rxkrafted]

Hi i would just like to ask something as well

In the event of a COPD patient having respiratory failure previously already on oral theophylline (10mg/kg/day elderly ex smoker)(however no levels ever taken before), has there ever been practice in giving a loading dose of aminophylline without any levels taken or should infusion maintenance dose only be given in such acute exacerbation case?

If the patient has already been taking theophylline, I'd probably want to see a level before loading a dose. Also, I don't see a practical scenario where they would want to even go that route considering this is like 3rd line agent for COPD management per guidelines (from what I remember).

 

[BidingMyTime]

OK, color me dumb, but how does glucagon work for food impaction? How is it given?

 

[lord999]

Hi i would just like to ask something as well

In the event of a COPD patient having respiratory failure previously already on oral theophylline (10mg/kg/day elderly ex smoker)(however no levels ever taken before), has there ever been practice in giving a loading dose of aminophylline without any levels taken or should infusion maintenance dose only be given in such acute exacerbation case?

No, you take levels unless you want the patient to possibly receive a "bonus" side of V-tach with that order. Also, you need to check on pH (do not initiate in acidosis), potassium, and calcium as those are what causes the toxicity effects.

More generally, just because someone's not done good practice prior to you doesn't mean you have jump the cliff like the other lemmings. Sometimes you reassess as a pseudo New admit if you think there's a cleanup job involved.

 

[beautifulrobot]

OK, color me dumb, but how does glucagon work for food impaction? How is it given?

Glucagon relaxes smooth muscle in the GI tract, and particularly the lower esophageal sphincter in relation to food impaction. I've never actually come across an order for it for this indication firsthand, but per the literature it is usually administered IV for this purpose.

 

[TimeZero]

OK, color me dumb, but how does glucagon work for food impaction? How is it given?

1 mg IV is the dose, which makes it easy. However, in the words of an ED doc I used to work with, "that **** don't work".

 

[GravityBeetle]

3). Varies per institution- ours is 5,000 uni max bolus for VTE

My institution says nothing. Ended up giving like 7000 units bolus to a ~90 kg pt. *shrug*