Problem with PGY2's?

[gwarm01]

I relate to this. It was an initial source of friction where I work at that I was being “too aggressive” with my vanco dosing.

Never mind that most of the staff are so ridiculously under aggressive that we have people who complete therapy without ever getting to goal, obviously the real problem is me and actually wanting to get to goal before the end of therapy.

I had the exact same issue! My reasoning? Well, they are in the ICU with a blood stream infection so I would rather be aggressive and heal them than waffle around for three days while they are sub-therapeutic. I was only emboldened when I read an article that showed the risk of AKI with vancomycin was greatly overestimated and that it was older formulations of the drug that were riskier for that. I'm not sure if that is still the case, because I have ran as far away from that work environment as is possible while still retaining a "pharmacist" title.

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[lane one]

I think everyone is guilty of some degree of prioritization and queue filtering. But if there are stat orders in the queue >30min anywhere in the hospital maybe it means that primary pharmacist is slammed and could use some help? It’s incredibly inconsistent whether anyone sees that and helps or not. When I run into that scenario I usually open up the queue for the whole hospital and if everywhere is that behind I just start from the top and help clean things up from everywhere, not just the ED. But if the whole house queue is completely empty except for 20+ ED orders it’s pretty obvious when they’re being blatantly avoided.

Lol I was kidding about working together, but I suspect there is similar friction at most hospitals with dedicated ED pharmacists. If the house is empty, then yes I agree that they should be helping more. Usually the situation we find ourselves in is that everyone is swamped and the ED is better staffed on a pharmacist to patient basis than anywhere else in the hospital, including the ICUs.

I relate to this. It was an initial source of friction where I work at that I was being “too aggressive” with my vanco dosing.

Never mind that most of the staff are so ridiculously under aggressive that we have people who complete therapy without ever getting to goal, obviously the real problem is me and actually wanting to get to goal before the end of therapy.

Operant conditioning at its finest. Considering most patient's started on vanc don't grow MRSA, no one's getting their hand slapped for that initial trough of 7mcg/ml. But that trough of 31mcg/ml is certainly going to raise some eyebrows. Naturally people start to catch onto the fact that lower initial dosing is safe from ridicule, and so that's exactly what they do.

 

[Sparda29]

I'm right there with you on this one. I once had a confrontation with a pharmacist who was angry that I dosed vancomycin "too high" on a patient, even though the the trough came back at exactly 15. I guess he had some sort of arbitrary max dose in his mind that we weren't supposed to cross. He tried to dress me down in front of half the staff, but I think I put him in his place. I even got him to admit I made the right call this time, but that I shouldn't do it again. I guess the right call can only be made by specific people.

I always think back to one of my professors, who also happened to be head of the antimicrobial stewardship program at the hospital where I was an intern, who shared a story about a patient on vancomycin. They were admitted to a community hospital and were septic. It was a pediatric patient, and you know they like to clear things fast, so they were having trouble getting the trough where it needed to be. When the providers tried to order a dose greater than 15 mg/kg, the pharmacists absolutely refused to allow it. Not a single one would verify that order, because 15 mg/kg is the MAX dose per Lexicomp or something like that. They had to air lift the patient to our hospital, where we probably bumped them up to something like 17 mg/kg q8h, and the patient was taken care of in short order.

Anyway, that was sort of a rambling way to say medicine is an art and sometimes you aren't going to find the exact answer in a book. That's why I can't stand these know it all pharmacists who have no flexibility in their practice.

I relate to this. It was an initial source of friction where I work at that I was being “too aggressive” with my vanco dosing.

Never mind that most of the staff are so ridiculously under aggressive that we have people who complete therapy without ever getting to goal, obviously the real problem is me and actually wanting to get to goal before the end of therapy.

I don't know what it is with the older pharmacists and the older ID physicians about Vancomycin dosing. For them it's either 1 gram q12 or q24.

I was relatively new at this place working overnights when we got a young obese patient who needed Vancomycin. I recommended to the 1st year resident a dose of 2 grams q6h and he accepted it. People in the morning were freaking out about it. Next day the trough came back at a nice 19.

 

[confettiflyer]

I don't know what it is with the older pharmacists and the older ID physicians about Vancomycin dosing. For them it's either 1 gram q12 or q24.

I was relatively new at this place working overnights when we got a young obese patient who needed Vancomycin. I recommended to the 1st year resident a dose of 2 grams q6h and he accepted it. People in the morning were freaking out about it. Next day the trough came back at a nice 19.

Hrm. Did you recheck a trough 2-3 days later?

 

[StockPharmD2020]

Hrm. Did you recheck a trough 2-3 days later?

You're asking Sparta.

 

[confettiflyer]

You're asking Sparta.

lol rhetorical question since we all know what happens when you give an obese patient 2 gm q6hrs

spoiler alert... 4th dose isn't magically the point of steady state.

 

[Sparda29]

lol rhetorical question since we all know what happens when you give an obese patient 2 gm q6hrs

spoiler alert... 4th dose isn't magically the point of steady state.

It was checked again and it came back at 24 (no big deal). Then we just reduced it to 1.5 q6h.

 

[confettiflyer]

It was checked again and it came back at 24 (no big deal). Then we just reduced it to 1.5 q6h.

That’s actually not bad. Large Vd with fat tissue gets screwy on kinetics.

Sometimes it’s a Zyvox kinda day, though.

 

[Dred Pirate]

That’s actually not bad. Large Vd with fat tissue gets screwy on kinetics.

Sometimes it’s a Zyvox kinda day, though.

Agree with the Zyvox in that case. We limit initial Vancs to 2 grams q 8 because we had to many people get overly aggressive and hit Troughs of 40+ a couple of times. But seriously, don’t people use dosing monograms anymore? I have read studies that show they are more accurate than people trying to calculate doses.

 

[Sparda29]

Agree with the Zyvox in that case. We limit initial Vancs to 2 grams q 8 because we had to many people get overly aggressive and hit Troughs of 40+ a couple of times. But seriously, don’t people use dosing monograms anymore? I have read studies that show they are more accurate than people trying to calculate doses.

My per diem hospital has a monogram that I use at the full-time hospital. I also have a Vanco Pk calculator in an excel spreadsheet that I use.

 

[lane one]

Nomograms are for dosing, monograms are for flannel pjs.