Seniors do you have any common drug list for clinicals and externships?

[cool_vkb]

I was thinking of making a list of drugs used commonly during our externships and clinicals. like a combo of antifungals, antibiotics, NSAIDs, and other imp ones.

any help will be appreciated.

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[Feli]

It really depends on what hospitals you go to and what their favorites are (and what their formulary offers). Just like fixation options in surgery, meds are really dealer's choice, and there are usually multiple ways to skin the cat (yet each place thinks their way is the best, so give the answer they will want if you have rotated there and know their preferences).

Below is a list of some of the more common ones I've seen used. It'd probably be a good idea to be familiar with them and their use/coverage for rounds/academics/interviews (esp bold ones which you will see used almost anywhere in pod surg service). I usually memorize generic names since that's what's more commonly used on boards exams and listed in journals, but you need to know brand names too (since that's usually how they're referred to by the attendings). Dosages are up to you... if your brain works that way (rote memory), you can go for it. If not, maybe try for at least some of the real commonly used ones in bold. In reality, you will (or at least "should") always double check in your book whenever you write Rx orders, even if you're 95% sure you know the dosage. Since you'll be looking them up anyways, I think there are better things to use your time on than memorizing dosages of 100+ meds, but JMO...

*disclaimer: I'd doing this mostly off the top of my head and my spelling sucks on non-English words, so go look em up to verify before you write a Rx order (or risk looking like an idiot when nurses/pharmacy/other docs read your order for amupcyllen/selbactum)

Clinic Rx:
-Pain/inflammation: Tylenol #3 and #4, hydrocodone (Vic, Lortab), Norco (hydrocodone also, but note it has less acet than Lortab or Vic), oxycodone (most won't use this, some do), Mepergan Fortis (ditto), propoxephene, methylprednisone, tylenol, indomethacin, tramadol, NSAIDs totally depending on preferences...celecoxib, ibuprofen, diclofenac, naproxen, etc
-PO Abx: cephalexin, amox/clav, clinda, tmp/smx, cipro, metronidazole, cefuroxime, levofloxicin, terbinafine
-Topical Abx: bacitracin, mupirocen, gentamycin, silver sulfa, triamcinolone, hydrocortizone, Lotrisone, miconazole, naftifine, etc
-Injected: lido, bupi, steroids are clinic pref (dex, triamcinolone, etc)

In ER/ inpatients /peri-op:
(all of the ones mentioned above... IV/PO ones like clinda, tmp/smx, etc are usually given IV if the pt has a line in)
-Abx: vanco, linezolid, amp/sulbactam, pip/tazo, cephazolin, ceftazidime, ceftriaxone, cefepime, imipenem
-IV/IM pain meds: morphine, meperidine (great med but not available everywhere), hydromorphone, ketorolac, fentanyl
-Anticoag: heparin, ASA, enoxaparin, warfarin
-Misc: etomidate, propofol, midazolam, diazepam, orphenadrine, meclopramide, ondansteron, promethazine, omeprazole, zolpidem, colchicine

 

[cool_vkb]

It really depends on what hospitals you go to and what their favorites are (and what their formulary offers). Just like fixation options in surgery, meds are really dealer's choice, and there are usually multiple ways to skin the cat (yet each place thinks their way is the best, so give the answer they will want if you have rotated there and know their preferences).

Below is a list of some of the more common ones I've seen used. It'd probably be a good idea to be familiar with them and their use/coverage for rounds/academics/interviews (esp bold ones which you will see used almost anywhere in pod surg service). I usually memorize generic names since that's what's more commonly used on boards exams and listed in journals, but you need to know brand names too (since that's usually how they're referred to by the attendings). Dosages are up to you... if your brain works that way (rote memory), you can go for it. If not, maybe try for at least some of the real commonly used ones in bold. In reality, you will (or at least "should") always double check in your book whenever you write Rx orders, even if you're 95% sure you know the dosage. Since you'll be looking them up anyways, I think there are better things to use your time on than memorizing dosages of 100+ meds, but JMO...

*disclaimer: I'd doing this mostly off the top of my head and my spelling sucks on non-English words, so go look em up to verify before you write a Rx order (or risk looking like an idiot when nurses/pharmacy/other docs read your order for amupcyllen/selbactum)

Clinic Rx:
-Pain/inflammation: Tylenol #3 and #4, hydrocodone (Vic, Lortab), Norco (hydrocodone also, but note it has less acet than Lortab or Vic), oxycodone (most won't use this, some do), Mepergan Fortis (ditto), propoxephene, methylprednisone, tylenol, indomethacin, tramadol, NSAIDs totally depending on preferences...celecoxib, ibuprofen, diclofenac, naproxen, etc
-PO Abx: cephalexin, amox/clav, clinda, tmp/smx, cipro, metronidazole, cefuroxime, levofloxicin, terbinafine
-Topical Abx: bacitracin, mupirocen, gentamycin, silver sulfa, triamcinolone, hydrocortizone, Lotrisone, miconazole, naftifine, etc
-Injected: lido, bupi, steroids are clinic pref (dex, triamcinolone, etc)

In ER/ inpatients /peri-op:
(all of the ones mentioned above... IV/PO ones like clinda, tmp/smx, etc are usually given IV if the pt has a line in)
-Abx: vanco, linezolid, amp/sulbactam, pip/tazo, cephazolin, ceftazidime, ceftriaxone, cefepime, imipenem
-IV/IM pain meds: morphine, meperidine (great med but not available everywhere), hydromorphone, ketorolac, fentanyl
-Anticoag: heparin, ASA, enoxaparin, warfarin
-Misc: etomidate, propofol, midazolam, diazepam, orphenadrine, meclopramide, ondansteron, promethazine, omeprazole, zolpidem, colchicine

aaah thank u very very much.

 

[Feli]

aaah thank u very very much.

NP, I'm always glad to help people who are interested learn more. Maybe some other 4th year students or residents can chime in with more meds, but that list includes most of the Rx I see commonly used for F&A service.

 

[PADPM]

Feli,

That's an excellent list, but just as a clarification and not to confuse anyone, some of the meds you listed under topical Abx (antibiotics) are actually topical anti-inflammatory/steroid preparations, such as triamcinolone, hydrocortisone, and of course some of the others antifungal.

I'm confident you're aware of that fact, I just wanted to make sure others understood the differentiation.

It was also interesting to see that meperidine/Demerol is not available everywhere. When I was a resident, it was really the gold standard for pain management. I'm not sure if it's not used as much anymore due to it's potential for abuse or because of other more efficacious medications. I know a lot of hospitals prefer Toradol due to it's non-narcotic status, but I also know a lot of hospitals use Dilaudid quite a bit, which has just as much abuse potential as Demerol. I believe it may have something to due with causing respiratory depression, but not sure why it's not available in some of your facilities.

 

[diabeticfootdr]

I know a lot of hospitals prefer Toradol due to it's non-narcotic status, but I also know a lot of hospitals use Dilaudid quite a bit, which has just as much abuse potential as Demerol. I believe it may have something to due with causing respiratory depression, but not sure why it's not available in some of your facilities.

Demerol can cause unprovoked seizures if given multiples does, since it's metabolite has a long half life and can accumulate.

 

[PADPM]

I thought that was only true if a patient had renal insufficiency. From what I understood, the half-life of meperidine was relatively short, but it's metabolite normeperidine could remain for quite a long time in patients with renal insufficiency. And those were the patients that I believed were in danger of multiple doses.

I was under the impression that in a "healthy" patient with a normal functioning liver, kidney, etc., Demerol/meperidine was still relatively "safe", although all narcotics must be used prudently.

 

[diabeticfootdr]

I thought that was only true if a patient had renal insufficiency. From what I understood, the half-life of meperidine was relatively short, but it's metabolite normeperidine could remain for quite a long time in patients with renal insufficiency. And those were the patients that I believed were in danger of multiple doses.

I was under the impression that in a "healthy" patient with a normal functioning liver, kidney, etc., Demerol/meperidine was still relatively "safe", although all narcotics must be used prudently.

All true, but I think that's the reason it fell out of favor. Apparently morphine and fentanyl are "safer".

 

[PADPM]

And drug addicts rarely ask for fentanyl because of it's short duration!!

This post actually reminds me of a funny story. When I was a resident, we did a rotation through a prison system. The inmates used to always have "lots of pain", no matter what procedure was performed. Even if the diagnosis was tinea pedis, they always asked for a strong narcotic....by specific name.

So one day a new resident who was a little "naive" was treating a prisoner and the prisoner kept asking for "dilaudid", but due to his heavy accent, the resident couldn't understand him. Additionally, the prisoner was simply being treated for a very minor sprain. So, the resident wrote for Dolobid, since the prisoner's pronunciation was "dalaudid" and he thought he was trying to say "Dalawbid".

Dolobid isn't used much anymore, but years ago was a relatively popular NSAID. He wrote an RX for the inmate, and the inmate was very happy to obtain the RX but must have been very disappointed later when he realized it wasn't what he REALLY wanted and didn't get the "buzz" he expected.

The senior residents knew what the inmate wanted, but let the RX go through as Dolobid, since a narcotic wasn't indicated and the entire situation was pretty funny. It was even funnier the following week when the inmate had a follow appointment with the new resident!

 

[Feli]

I still want to try giving a malingering pt a script for PO Demerol one day... not Mepergan Fortis, just PO Demerol (sans Phenergan)... will probably have to wait until I'm an attending for that, though. I doubt many formularies/pharmacies have it. One surgery professor joked in a lecture that it's the best Rx to give a clearly drug seeking office patient (apparently, the PO form has constipation,nausea, and other side effects that are so bad it just may get them to kick the habit... or at least go to another doc for their next opiod Rx).

I'd have to check, but I think our hospital allows PCA and anesthesia use of Demerol. I also think you can write single doses IM/IV post-op or mod/severe pain... not listed as restricted in the online formulary.

 

[PADPM]

Additionally, the oral form of Demerol/meperidine is not nearly as efficacious as the IM/IV/SC form. I believe that the ratio is approx: 5:1 or 6:1 to get the same effect. So you'd have to take about 300 mg of the oral form to obtain the same effect as 50 mg of the parenteral form.

Although I know you're joking, I would never recommend giving a patient a specific RX in "spite".....if I suspect a drug seeker I simply tell the person I won't write for a narcotic. It's that simple. He/she knows where to go to get their drugs and will be quick to tell his/her "buddies" where NOT to go!

 

[podpal]

Meperidine, Demerol has a short duration and must be readministered. Adding it along with Vistaril means taking time to draw up both meds. IM requires administration several times meaning more patient "pokes". If IV access is established, a Morphine drip is easier for a post op patient. Fentanyl, as a Duragesic patch, is also a reasonable pain reliever for long term, chronic pain conditions, such as terminal cancer.

Remember that Tramadol is a good agent for pain.

Any patient with indication of prior drug abuse should have particular pain management consideration. If the patient is already detoxed and no longer abuses narcotics, then it is important to avoid non narcotic pain options. If the patient is a current narcotic user/abuser, such as heroin, etc., then they may require a larger dose of narcotic to reduce pain and to avoid detox. It is prudent to avoid narcotics in this population if possible, however, in my opinion, it's better to have a patient with adequate narcotic on board than to go into detox.

It's nice to see that facilities are getting away from the old Demerol/vistaril injections. They weren't that great and much better options for pain management currently exist.

 

[PADPM]

You make some excellent points. The "classic" Demerol/Vistaril combination did work very well, as I had it many years ago in the E.R.

The Vistaril had several actions. It potentiated the Demerol, thereby allowing the narcotic dosage to be slightly less, it worked to decrease nausea and it also acted to decrease potential itching since many narcotics are known to cause a "narcotic itch". Even patients taking oral meds such as hydrocodone, oxycodone, etc., often report an overall "itch", although there is no rash or allergic reaction.

One of the problems with Vistaril is that it was/is quite a painful injection.

What I've always found interesting about administering injectable Toradol for some analgesia is that although it often can decrease pain, patients that have had a narcotic in the past often wait for that "buzz" or feeling of euphoria they get with a narcotic, and of course that doesn't happen with Toradol. And I actually believe that "buzz" or euphoria from the narcotic often takes the edge off and has a potential benefit. When the patient gets that feeling, they relax and know the drug is working. With Toradol, they never get that feeling and often don't have as much confidence that the drug is working.

There are also other alternatives that aren't used that often such as Talwin, Nubain and Stadol. Stadol was actually relatively popular many years ago and had a nasal spray that was popular for patients that were nauseous, because they couldn't vomit up the pill.

The problem with the above mentioned drugs is that they are all narcotic agonists/antagonists and must be used with extreme caution in patients with a history of drug abuse.