Post an interesting case

[Dred Pirate]

Been awhile since we had some good clinical discussion - paste a good / interesting / crazy pharmacy related case - I need something more than the outlook on our profession - haha

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[PolarPop]

When I worked in the hospital I saw a really weird case of anion gap metabolic acidosis caused by oxacillin. We all thought must be the oxacillin at first but couldn't figure out the mechanism because no one had ever seen it do that. I saw some cases reported with flucloxacillin where it causes a build up of pyroglutamic acid which then causes the high anion gap. We tested her urine for it and her level was way above normal. It was pretty exciting at the time.

 

[nampa]

When I worked in the hospital I saw a really weird case of anion gap metabolic acidosis caused by oxacillin. We all thought must be the oxacillin at first but couldn't figure out the mechanism because no one had ever seen it do that. I saw some cases reported with flucloxacillin where it causes a build up of pyroglutamic acid which then causes the high anion gap. We tested her urine for it and her level was way above normal. It was pretty exciting at the time.

Who was monitoring that? We usually leave that to the MDs. How did you idenitfy that?

 

[Dred Pirate]

I will add my story
Pt with hyperkalemia, treated, admitted.
repeat K normal
follow up k at 2 am - high (can't remember how high)
Cardiology NP calls and asks me if they just treat the same
I look at labs- WBC is something like 50k. I ask if pt has leukemia - NP - we are still trying to figure that one out. I say it might be TLS to get a uric acid and she needs to talk to her supervising MD or call the ICU doc. She seems sheepish. Another MD not related to the pt overhears my conversation and asks for my phone (he can hear both sides of convo) and said he has seen that before, and the pt can go down hill very fast.
Turns out I was right, uric acid high, TLS diagnosed, rasburicase started.

 

[PolarPop]

Who was monitoring that? We usually leave that to the MDs. How did you idenitfy that?

Weekly labs emailed to me and the ID attending

 

[JustFillIt]

How about this one….

Levothyroxine 1200 mcg once weekly before bed with no interacting meds/foods.

What do you think?

 

[storyhill2]

I will add my story
Pt with hyperkalemia, treated, admitted.
repeat K normal
follow up k at 2 am - high (can't remember how high)
Cardiology NP calls and asks me if they just treat the same
I look at labs- WBC is something like 50k. I ask if pt has leukemia - NP - we are still trying to figure that one out. I say it might be TLS to get a uric acid and she needs to talk to her supervising MD or call the ICU doc. She seems sheepish. Another MD not related to the pt overhears my conversation and asks for my phone (he can hear both sides of convo) and said he has seen that before, and the pt can go down hill very fast.
Turns out I was right, uric acid high, TLS diagnosed, rasburicase started.

Nice. It's good to have some of those kind of interventions.

 

[storyhill2]

I had a patient during a cardiac arrest that came from out of hospital. We couldn't get get them back after multiple pulse check and various code meds that I forget specifically. We were probably 20 minutes into the code and this person had been down for a while in the field. Doc announced last round of meds and then pulse check. We were basically going through the motions and based from past experience we all knew it was over and doc would annouced deceased time but at the last pulse check the nurse said, "I feel a pulse". We ended up getting ROSC and patient survived the experience. A good reminder there is always a chance even if it seems small.

 

[Sparda29]

I had a patient during a cardiac arrest that came from out of hospital. We couldn't get get them back after multiple pulse check and various code meds that I forget specifically. We were probably 20 minutes into the code and this person had been down for a while in the field. Doc announced last round of meds and then pulse check. We were basically going through the motions and based from past experience we all knew it was over and doc would annouced deceased time but at the last pulse check the nurse said, "I feel a pulse". We ended up getting ROSC and patient survived the experience. A good reminder there is always a chance even if it seems small.

Survived plus had normal/semi-normal brain function?

 

[storyhill2]

Survived plus had normal/semi-normal brain function?

good point. I only checked on them the next day and they were still alive.

 

[Sparda29]

good point. I only checked on them the next day and they were still alive.

Wow, similar thing happened with the Bills player I guess.

 

[nampa]

Been awhile since we had some good clinical discussion - paste a good / interesting / crazy pharmacy related case - I need something more than the outlook on our profession - haha

Pt. with severe hyperglycemia--300plus on flr. nurse calls asking why the insulin drip isn't bringing bg down. looked and saw the insulin was in dextrose, not saline. anyone see this or surprised by it?

 

[Dred Pirate]

Pt. with severe hyperglycemia--300plus on flr. nurse calls asking why the insulin drip isn't bringing bg down. looked and saw the insulin was in dextrose, not saline. anyone see this or surprised by it?

was this a compounding error? The dextrose would obviously impact, but if you have a 1 unit / ml standard drip - a 100ml bag would have 5 grams (if in D5W) - so not that much in the whole scheme of things compared to the amount of insulin the patient would get.
I suspect there was more to the story

 

[Rockinacoustic]

Pt. with severe hyperglycemia--300plus on flr. nurse calls asking why the insulin drip isn't bringing bg down. looked and saw the insulin was in dextrose, not saline. anyone see this or surprised by it?

It's not uncommon to have all drugs in D5W for patients with severe hypernatrenia. And even patients in DKA will eventually end up on a dextrose infusion with insulin until their gap closes.

I had a situation similar to this where the insulin drip "wasn't touching the sugar". Turned out the RN programmed the pump at 0.1units/hour instead of 0.1units/kg/hr...

 

[Dred Pirate]

It's not uncommon to have all drugs in D5W for patients with severe hypernatrenia. And even patients in DKA will eventually end up on a dextrose infusion with insulin until their gap closes.

I had a situation similar to this where the insulin drip "wasn't touching the sugar". Turned out the RN programmed the pump at 0.1units/hour instead of 0.1units/kg/hr...

another common error is not wasting enough of the drip through the line to saturate the tubing since insulin will bind with it

 

[nampa]

It's not uncommon to have all drugs in D5W for patients with severe hypernatrenia. And even patients in DKA will eventually end up on a dextrose infusion with insulin until their gap closes.

I had a situation similar to this where the insulin drip "wasn't touching the sugar". Turned out the RN programmed the pump at 0.1units/hour instead of 0.1units/kg/hr...

another common error is not wasting enough of the drip through the line to saturate the tubing since insulin will bind with it

Interesting, so you are saying that the dextrose isnt enought? What amount is it usually run through? How much dextrose and insulin sol. is enough?

 

[Dred Pirate]

Interesting, so you are saying that the dextrose isnt enought? What amount is it usually run through? How much dextrose and insulin sol. is enough?

that isn't enough dextrose to mess with the BG - I mean once the BG hits a certain point we run d51/2NS at 100 to keep enough dextrose / insulin to help clear the ketones

 

[owlegrad]

We had a case of human trafficking exposed. The victim was reunited with their family that had reported them missing two years prior.

Perhaps not exactly the type of interesting that this thread is meant for but I figured it was worth sharing.

 

[CetiAlphaFive]

We had a case of human trafficking exposed. The victim was reunited with their family that had reported them missing two years prior.

Perhaps not exactly the type of interesting that this thread is meant for but I figured it was worth sharing.

Holy ****

 

[owlegrad]

Holy ****

Yeah here in Florida they require human trafficking CE (I think) as well as posters but I never thought we would see an actual case of it. It’s hard to believe that really happens.

 

[CetiAlphaFive]

Yeah here in Florida they require human trafficking CE (I think) as well as posters but I never thought we would see an actual case of it. It’s hard to believe that really happens.

Yeah, we are required to do an hour too.

When i was a P4 i had to do intern hours in another town. I would carpool with a very barbie girl person who was a super Americanized, non Latina/e/x monitory.

Once, we were driving home and saw border patrol SUV's suddenly flying down the road. About 10 minutes after, a small truck or van (can't remember) passed us, then pulled over and did the clown car routine. About 20 migrants piled out and fled into the country side.

My buddy was like "AHHHHH what do we do?". Wish em well.

 

[RXDOC1986]

We are a level II Trauma, Regional Medical Center. We get the most interesting ER admits, especially when a full moon, on a Fri/Sat night. It's absolutely astounding how long some people (men) hold off, before they come in (at 3am) to wait 4hrs to be seen for something major. We look at pictures of gangrenous toes, pressure sores that are bone deep, Gunshots when the victim "cannot" recall when, where, who, or even how many times he was shot. Drug Dealers that swallow their whole stash when they are chased by the police and then will not tell us how many baggies of what they ingested.
We had a gentleman walk in, filled out all the paperwork, went back to his seat in the waiting room, patiently waited for two hours, with a knife sticking out of his back, between the shoulder blades. Nobody noticed, until someone read his paperwork.
I couldn't make this chit up, if I tried.

 

[BidingMyTime]

How about this one….

Levothyroxine 1200 mcg once weekly before bed with no interacting meds/foods.

What do you think?

Surprised no one else responded to this. Several years ago, there was talk about a study that showed high-dose once weekly levo was just as effective as smaller doses once daily. Unfortunately, I never heard anything more about it after the initial news, clearly QD prescribing is still the norm. If the patient has been on the weekly dose and has no issues, then I'd have no problem continuing the order.

 

[shorteeee]

Surprised no one else responded to this. Several years ago, there was talk about a study that showed high-dose once weekly levo was just as effective as smaller doses once daily. Unfortunately, I never heard anything more about it after the initial news, clearly QD prescribing is still the norm. If the patient has been on the weekly dose and has no issues, then I'd have no problem continuing the order.

That's interesting because I have a patient who takes levothryoxine nightly right now but his thyroid levels are all messed up, think amio induced but amio been stopped for more than 6 months now. I wonder if it makes a difference of her takes in the morning empty stomach or nighttime. His tsh is very low so we are titrating the dose now.

 

[Rockinacoustic]

Had a patient admitted for recurrent ishemic strokes despite being on apixaban. Previously "failed" rivaroxaban. Neuro was requesting a PA for dabigatran when I noted they were on primidone for essential tremors all this time. Was able to titrate them off primidone and no issues since.

Not a sexy case, but made a difference.

 

[sadface]

Had a patient admitted for recurrent ishemic strokes despite being on apixaban. Previously "failed" rivaroxaban. Neuro was requesting a PA for dabigatran when I noted they were on primidone for essential tremors all this time. Was able to titrate them off primidone and no issues since.

Not a sexy case, but made a difference.

This makes me feel vindicated for arguing with three doctors about that interaction before

 

[BidingMyTime]

That's interesting because I have a patient who takes levothryoxine nightly right now but his thyroid levels are all messed up, think amio induced but amio been stopped for more than 6 months now. I wonder if it makes a difference of her takes in the morning empty stomach or nighttime. His tsh is very low so we are titrating the dose now.

Any reason not to add on T3 or a T3/T4 combo? Sometimes just adding on more of the same (ie T4) isn't going to move the needle as much as trying something different.