Archive for March, 2010

ICU- Day 1

March 29, 2010 at 4:34 pm · Filed under Clinical Interventions, Reflections on Residency & Learning ·Tagged , , ,

First day back from a month of vacation + project and I’m starting to enjoy it already.

Glen a very friendly and patient teacher, but the BEST part is that Glen is also a visual learner!!!! Yay!
Today, I got a chance to assess a theophylline level with Glen.

Theophylline is a methylxanthine, so it’s very similar to caffeine. It can cause adverse effects such as insomnia, so it’s best taken in the morning. Theophylline is metabolized in the liver and has many drug interactions, including:

Bupropion (probable) Cimetidine (probable) Ciprofloxacin (established) Enoxacin (established) Erythromycin (probable) Ethinyl Estradiol (theoretical) Etintidine (probable) Etonogestrel (theoretical) Fluvoxamine (established) Halothane (probable) Idrocilamide (probable) Imipenem (theoretical) Levofloxacin (theoretical) Mestranol (theoretical) Mexiletine (probable) Norelgestromin (theoretical) Norethindrone (theoretical) Norgestrel (theoretical) Pefloxacin (probable) Peginterferon Alfa-2a (probable) Rofecoxib (probable) Thiabendazole (probable) Troleandomycin (probable) Zileuton (probable)

Today we went over why a patient is admitted to the ICU:

1) Respiratory failure
a) ventrilation ( moving in/out of lung)–> assess by arterial CO2 ( normal is 35-45)
b) respiration ( air moving in/out of body)–> assess by arterial O2 ( normal 100-110)

2) Shock- inadequate TISSUE PERFUSSION
a) organ dysfunction
– brain –> decrease LOC
– Kidney–> u/o
– Skin –> cold/blue
b) lactate ( anaerobic metabolism–> cells run out of oxygen before nutrients first; therefore, use anaerobic metabolsim, long half life, metabolized by liver)
c) mixed venous oxgenation pressure saturration ( using swan-ganz or pulmonary artery occlussion.. balloon) –> Normally 70-75mmHG ( want some reserve oxygen to perfuse tissues, check venous blood back to lung)

3) neurological disorder

4) burn

Other terms:

  • roux en y:
    the Roux-en-Y anastomosis looks like the letter Y; typically, the two upper limbs of the Y represent a proximal segment of small bowel and the distal small bowel it joins with (which is often a blind end), and the lower part of the Y the distal small bowel (beyond the anastomosis).
    Roux-en-Ys are used in several operations and collectively called Roux operations
  • PEEP: positive expiratory pressure
  • extubate: To remove a tube from a hollow organ or passageway, often from the airway. The opposite of extubate is intubate.
  • air is composed of 21% oxygen, 75% nitrogen, less than 1% carbon dioxide
  • prophy: DVT, stress ulcer, glucose
  • FiO2= faction of oxygen
  • nonverbal condition to watch out for: sleep/hunger/pain
  • SABA doses are higher in ICU patients with endotracheal tube–> drug sticks to tube
  • Chest XRay–> good to look for pulmonary edema
  • things to watch out for to help with breathing:
    1) Diuresis ( edema?)
    2) CNS depressant–> Able to breath as much as he wants to
    3) abx
    4) bronchodilators
    5) anti-inflammatory
  • bullae- big alveoli ( bad…less surface area)

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ID- Week 4

March 7, 2010 at 10:10 pm · Filed under Reflections on Residency & Learning ·Tagged , , , ,

Regional case wide presentation on Friday. I wish I had answered the questions better…I need learn and calm down when answering questions

Cross sensitivity between carbapenem and penicillin:

A wide range of cross-reactivity between penicillins and carbapenems has been reported in various studies; however, more recent prospective studies have shown the incidence of cross-reactivity between penicillin and carbapenem skin tests to be around 1%. (1)

Concerning cross-reactivity between penicillins and carbapenems, three retrospective clinical studies reported rates of reaction to carbapenems of 9 to 11 percentamong inpatients with a reported penicillin allergy. (1,2,3)

The frequency of carbapenem hypersensitivity was reported as 9.2% versus 3.9% (15 of 163 patients with vs 4 of 103 without reported penicillin allergy, p=0.164). (5)

References:

(1) Frumin J, Gallagher JC.Allergic cross-sensitivity between penicillin, carbapenem, and monobactam antibiotics: what are the chances?Ann Pharmacother. 2009 Feb;43(2):304-15. Epub 2009 Feb 3.

2. Prescott WA Jr, DePestel DD, Ellis JJ, et al. Incidence of carbapenem-associated allergic reactions among patients with versus patients without a reported penicillin allergy. Clin Infect Dis 2004;38:1102-1107. [Medline][UBC’s eLink

3. McConnell SA, Penzak SR, Warmack TS, Anaissie EJ, Gubbins PO. Incidence of imipenem hypersensitivity reactions in febrile neutropenic bone marrow transplant patients with a history of penicillin allergy. Clin Infect Dis 2000;31:1512-1514. [Medline][UBC’s eLink]

4.Sodhi M, Axtell SS, Callahan J, Shekar R. Is it safe to use carbapenems in patients with a history of allergy to penicillin? J Antimicrob Chemother 2004;54:1155-1157. [Free Full Text]

5. Medscape Pharmacists.Carbapenem Hypersensitivity in Patients with Penicillin Allergy: Clinical Studies. http://www.medscape.com/viewarticle/552160_3

FMI:

  • ampicillin= amoxicilin
  • pen po F: 60%; 600 mg ~ 1 million units; po only used for strep throat
  • no antiviral for adenovirus ( well, there is, but it is very toxic)
  • pip/tazo ~time dependent–> therefore, adjust dose
  • concentration dependent–> adjust interval

Drug Counselling:

LINEZOLID

  • indication: VRE, noscomial infx, skin infection, pneumonia
  • ADE: rash ( 0.4-7 %), GI ( diarrhea 2.8-11%, N/V), neurological ( headache 0.5-11.3%) , increase bp, myoclonus, tremor, twitching, fever, sertoneri s/s ( increase HR, sweating, dilated pupil); endocrine: lactic acidosis; hematologic: myelosuppression; neurological: periperhal neuropathy, seizure; ophthalmic: disorder of optic nerve
  • MOA: inhibit bacterial ribosomal translation
  • A: not affected by food

CHLORAMPHENICOL

  • inidcation: menignitis, CF, h influ infection, salmonella
  • ADE: neuro(confusion, h/a, neurtoxicity); ophthalmic(burning sensation in eye); psychiatric ( delirium, depression); CV ( gray syndrome in new born ); hematologic ( asplastic anemia–> bone marrow doesn’t prodduce sufficient red cell to replenish stores)
  • MOA: bacterostatic, bactericidal in high concentration, bind ribosome–> affect cell membrane
  • Monitor: fever, CBC with differentials q 2 days

NITAZOXANIDE

  • indication: c. diff ( off label), cryptoporidosis, giardiasis
  • ADE: GI ( abd pain, diarrhea, n/v); neurological ( H/A)
  • MOA: antiprotozoal activity–> interfere with pyruvate ferredoxin oxitreductase ( PFOR) enzyme dependent electron transfer –> needed for anaerboic energy metab
  • A: take with food
  • Monitor: improvement in diarrhea

COLISTIN

  • indication: GNB, pseudomonas, enterobacter aerogenes, e coli, klebsiella
  • ADE: neurolgoical ( dizziness, tingling senstation, paresthesia ( tingling, numbiness, pricking of skin); renal ( nephrotoxicity), resp ( acute resp failure or resp tract paralysis)
  • MOA: penetrate and disrupt cell membrane
  • Monitor : culture and sensitivity; CVC, s/s improvement, temp, renal function, S/S neuromuscular blockade

Meningitis Didactics

  • N meningitis passed by hugging, kissing  and other close contact ( ie. college dorms are high risk of sites due to close quarters)
  • dexamethasone may decrease risk of hearing loss in children
  • septra and FQ are alternatives if patients are allergic to beta lactams
  • dexamethasone has shown some benefit only in subgroup analysis for strep pneumo ( pro: decrease neurolgoical deficit; con: decrease inflammation leads to decrease abx penetration)
  • prophlaxis only for H influ and meningitis
  • acquired: contiguous, hematogenous, trauma
  • neonate: e coli, listeria, klebsiella, group C strep, lactobacillus (vaginal flora)
  • EVD if increase intracranial pressure ( increase infection, drain, hardward increases risk of infection)
  • 1/4 pt die despit tx
  • use + vanco if increase ceftriaxone resistance ( IVDU)
  • Japanese encephalitis (Japanese: 日本脳炎, Nihon-nōen)—previously known as Japanese B encephalitis to distinguish it from von Economo‘s A encephalitis—is a disease caused by the mosquito-borne Japanese encephalitis virus.
  • s/s of meningitis: fever, seizure, headache, mental status alteration, photophobia, looking at eye–> see papuillo edema ~ increased pressure, neck stiffness, hear loss, kernig sign ( lower extremities~ K is after B), brudzinski sign  ( Neck)
  • kids show non-specific features–> fever, irritability, crying, decrease eating
  • WBC : neutrophil ( bacteria), lymphocyte ( viral), monocyte ( listeria  monocytogenes), esoinphil ( allergy)
  • RBC : WBC        1000:1
  • viral = no increase in protein
  • inflammation can affect glucose transport mechanism
  • serum glucose should be checked ( CSF should be 50% of serum normally)

Vancomycin Tapering

Some authorities believe that patients suffering from repeated recurrences should be treated using a regimen consisting of the intermittent administration of  metronidazole (or vancomycin)over a period of weeks or even months and followed by their gradual tapering,or by prophylaxis with low dosesof these antibiotics given daily or on alternating days or weeks,or by use of cholestyramine or other anion binding medications along with specific antibiotics,especially at the end of therapy

Sanford: week 1- qid, week 2- bid, week 3- q24h, week 4-qod; week 5-6 q3d

Vancomycin taper:

Week 1: 10 mg/kg/dose (up to 125 mg) PO Q6 hours

Week 2: 10 mg/kg/dose (up to 125 mg) PO Q12 hours

Week 3: 10 mg/kg/dose (up to 125 mg) PO QD

Week 4: 10 mg/kg/dose (up to 125 mg) PO QOD

Week 5 and 6: 10 mg/kg/dose (up to 125 mg) PO Q3 days

OR Vancomycin pulse therapy:

10 – 40 mg/kg/dose (up to 125 – 500 mg) PO Q 2-3 days for 3 weeks

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ID- Week 3

March 7, 2010 at 10:00 pm · Filed under Presentations, Reflections on Residency & Learning ·Tagged ,

Presentation this Wednesday on need for double coverage in patients with pseudomonal pneumonia. The presentation was well attended and there was some discussion on the increasing resistance of 3rd gen ceph for pseudomonas aeruginosa.
  • For patients with c diff and toxic megacolon, TOC is po vanco
  • staph epi with hardware: vanco
  • sildenafil  & nitroglycerin=  Nitroglycerin works by increasing nitric oxide, and it helps with angina by opening up the arteries that supply the heart with oxygen. If you take nitroglycerin and Viagra together, the increased nitric oxide plus the blocking of PDE5 can lead to problems. Consistent with its known effects on the nitric oxide/cGMP pathway, sildenafil was shown to potentiate the hypotensive effects of nitrates. Deaths have been reported in men who were using sildenafil while taking nitrate or nitrite therapy for angina. Nitrates amplify the vasodilatory effects of sildenafil or other phosphodiesterase inhibitors (e.g., vardenafil) if coadministered and result in severe hypotension
  • perforation = rupture
  • enterococcus coverage endocarditis with prosthetic valve= gent + vanco x 6 wk
  • yeast= branching fungi= aspergillus
  • enterococcus found in GI (gut) and GU (bladder)
  • echo doesn’t exclude endocarditis
  • meningitis: ceftriaxone q12h in guidelines, but q24 h in study
  • UTI diagnosed by (1) urinalysis (2) urine culture (3) clinical signs and symptoms
  • pre- renal: Prerenal causes of AKI are those that decrease effective blood flow to the kidney. These include low blood volume, low blood pressure, and heart failure. Changes to the blood vessels supplying the kidney can also lead to prerenal AKI. These include renal artery stenosis, which is a narrowing of the renal artery that supplies the kidney, and renal vein thrombosis, which is the formation of a blood clot in the renal vein that drains blood from the kidney.

ex) Ramipril, an angiotensin-converting enzyme (ACE) inhibitor, is metabolized to a more potent ramiprilat (active drug). Both prevent the conversion of angiotensin I to angiotensin II, a vasoconstrictor agent, which decreases vasopressor activity and aldosterone secretion

ex) Furosemide is an anthranilic acid derivative and a potent diuretic that works by blocking the absorption of sodium and chloride in the kidney tubules (proximal and distal tubules, also in the loop of Henle), causing a profound increase in urine output .

  • intrinsic: Those causes that lead to damage to the kidney itself are dubbed intrinsic. Intrinsic AKI can be due to damage to the glomeruli, renal tubules, or interstitium. Common causes of each are glomerulonephritis, acute tubular necrosis (ATN), and acute interstitial nephritis (AIN), respectively.
  • postrenal: Postrenal AKI is a consequence of urinary tract obstruction. This may be related to benign prostatic hyperplasia, kidney stones, or an obstructed urinary catheter.
  • mucomucosa: erode into bone, in sinus, TOC: surgery, then amph B x months
  • azole: always check interactions
  • azole: static
  • echinocandin: static
  • amph: cidal
  • static: rely on immunsystem
  • invasive endocarditis: echinocandin
  • cidal for : (1) endocarditis (2) meningitis (3) neutropenic or immunosuppressed patients
  • combo antifungal use in the future
  • echinocandin work on cell wall
  • ketoconazole is oldest azole with the narrowest coverage, poor CNS penetration
  • fluconazole: good absorption, penetrate CNS
  • itraconazole: not well absorbed, good for aspergiosis, but not as good as voriconazole; liquid is better absorbed
  • posaconazole: same as vori, but better coverage
  • albican cultures are differentiated by: (1) pseudopod (2) germ tube
  • candiasis is a yeast; aspergillosis is a mold
  • azole is not as good for candida krusei or glabrata

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ID- Week 2

March 7, 2010 at 9:58 pm · Filed under Clinical Interventions, Reflections on Residency & Learning, Topics Discussed ·Tagged , ,

Interpreted gent dosing in synergistic therapy for endocarditis.
aim for post of 3-4 mg/L. Pre should be 1/2 hour before infusion. Post should be 1/2 hour after end of infusion.

ADE report for daptomycin submitted.
Patient had died suddenly of cardiac cause. Autopsy not performed. Dapto related?

FMI

  • anaerobe= foul smelling odour
  • ESBL: DOC carbapenem
  • treatment of urosepsis: 7-14 days
  • UTI: KEEP: klebsiella, e coli, enterococcus, pseudo
  • WBC increase ~ c. diff
  • CRP Increase ~ UTI
  • intra-abd infection: (1) abscess (2) primary or secondary peritonitis
  • neutropenic~ low neutrophil
  • amg causes neuroblockade
  • UTI: s/s:
  • Dysuria
  • Urinary urgency
  • Urinary frequency
  • Nocturia
  • Suprapubic heaviness or pain
  • Hematuria (more common in women)
  • New or increased urinary incontinence
  • Significant bacteriuria
  • Pyuria
  • Hematuria
  • Proteinuria

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