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Case Approach: A Resident Guide to Internal
Case Approach: A Resident Guide to Internal Medicine at UH Case Medical Center and the Cleveland VA 2015-2016 “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” -Rudolf Virchow 001 Program Directors Department of Medicine K. Armitage: 31552 33970 Weisman 33306 Ratnoff House Staff Pager Roster 2014-2015 C. Harwell: 36564 ALPHABETICAL Order 33559 Eckel Ambulatory Chief: 31529 440-562-0509 ORANGE MED 33726 Naff S. Singh: 440-562-0026 440-562-0491 WHITE MED 32605 Hellerstein VAMC Chief: 31533 440-562-0502 GREEN MED 32654 Wearn R. Mourad: 440-562-2465 440-562-0456 BLUE MED 32661 Carpenter UHCMC Chief Res: 31250 OnCall Pager Douglas Moore :30224 32299 Dworken Quality Chief: 36644 H Bhavsar 35129 DACR/NACR: 30512 PACS: 35030 Pager Last Name First Name Pager Last Name First Name 31318 Abdel Rahman Mohamed 33785 Fong Vincent 31329 Abdul Rahman Rania 36561 Garner Pager Last Name First Name 31815 Nayak Ashwini Will 38743 Ndubuizu Obinna 30570 Ade Timothy 36556 George Tiffany 31816 Ndum Ogechukwu 33387 Agwu Ogechi 37554 Ghosh Sohini 31595 Newman Tessa 30345 Alabdulkader Assim 35086 Gollamudi Jahnavi 38613 Olasokan Olapeju 39979 Alahmadi Asrar 31585 Graham John 37751 Patel Namrata 30163 Alajali Wissam 36503 Guzman Christina 38797 Patterson Andrew 33658 Aljorayid Abdullah 31663 Hambley Bryan 37317 Peluso Christopher William 37891 Pensiero Amanda 39287 Poynton Emily 33481 Al-Kindi Sadeer 33077 Hannah 39833 Almasoud Abdullah 37780 Harris Andrew 39499 Hlatshwayo Mati 38567 Prabhakar Dhivya Won Jin 38560 Pruthi Dafina 39650 Alotaibi Mona 31340 Alquraini Hussain 37772 Ho 37282 Alsalem Ahmed 37769 Hornick John 38557 Raj Rohit 39947 Alsallom Faisal 36495 Horstman Gabrielle 38575 Rali Aniket 36471 Al-Shathri Ziyad 37759 Hull Leland 35994 Riaz Anum 39866 Alyahya Mossaed 37764 Igboeli Blessing 32134 Richards Sindhu R. 32053 Banks Matthew 37784 Iovleva Alina 35902 Rios Nancy 35859 Barrero Ortiz Andres 37217 Iyer Arun 35781 Rizvi Macym 32030 Barrett Terry 31685 James Christine 35051 Robertson Leanna Marie 37757 Batt Courtney 36587 Jandali Bouchra 31452 Roh Justin Nupur 38568 Romero Rachel 33712 Baydoun Atallah 31699 Jhawar 32018 Berg Michael 37451 Johnson Angela 32008 Sabeh Mohamed 31394 Betbadal Anthony 37351 Jonna James 38573 Sadik Jacob Milana 31711 Kellie Lesley 36023 Selfridge Jennifer 31899 Bogorodskaya 36140 35945 Borinsky Elliott 37788 Khalid Khadieja 32017 Serhal Maya Bou-Abboud Carine 37522 Khanna Akriti 35658 Shah Ruchi 36109 Bowen Ted 37792 Khetan Aditya 32019 Shah Shenil 36164 Brady Elise Bonnema 36992 Khoury Katia 32023 Shaniuk Paul 36562 Kim Chang 38571 Sharma Rishi Stephanie 35715 Si Xin Sara 35617 Smith Kimone 36489 Buch Niranjani 36344 Budnick Susan 31730 Kim 36108 Burns Charles 38019 Kleinman 36379 Campbell Timica 31734 Koo Patrick 38530 Srivastava Neetika 36492 Chami Ahmad 35503 Kunkel Matthew 38455 Stehouwer Nathan 36199 Chan Megan 31760 Lee Rose 32034 Sullivan John 31424 Chen Dhruti Patel 32755 Lin Paul 38519 Summers Nathan 31450 Christopher Bridgette 31767 Linder Kathleen 38525 Szeto Brandon 36347 Coletta Paul 31771 Linz Christopher 38476 Thakker Prashanth 36415 Couturier Spencer 37329 Lundgrin Erika 32049 Thomas David 31480 Danawala Sejal 31403 Lyles Galina B. 38482 Thorton Gabriel 36184 Das Alvin 32371 Ma Vincent 32063 Tripathi Priyam 31481 Davis Georgia 31780 Madan Shivanshu 35833 Trotter Ashley 31487 Davitkov Perica 37183 Makani Amber 32079 Tuckerman Jason 36330 Dean Chad 32198 Mansoor Emad 35597 Uppal Saurav 36260 Dedhia Nikita 36211 Matto Faisal 32458 Volpe Peter 31488 Demachkie Perihan 31800 Michal Stephanie 35812 Wang Han 36345 Dhatt Roppa 31583 Miller Carlyann 33069 Wentworth Ashley 36384 Diamond Akiva 33106 Miranda Alexander 31258 Wetzel Lindsey 36403 Dickey Trisha 31461 Moini Megan 35958 Yasinow Scott Ahmad 31742 Drescher Cassandra 31641 Moria Yosra 36398 Younes 39370 Duncan Phillicia 37805 Morris Stephen 35832 Zachariah Robin 36152 Durchholz Christina 33101 Morrison Justin 36024 Zande Jonathon Ali 36945 Nadeem Fahd 35944 Zhang Andrew Anodika 31303 Natu Ashwinee 38460 Zhou Ning 36535 Faramarzalian 33778 Fatehchand 002 003 2-3 4 5 6-7 8 9-11 12-16 17 18-21 22-28 29-32 33-40 41-53 54-66 67-75 76-84 85-96 97-104 106-109 110-112 113-116 117-120 121-122 123 124-125 Table of Contents: Resident Pagers by Name, Poster Table of Contents Introduction Block Schedule Dates, Residency Calendar Pager Info VA Tips and Tricks, CPRS Notes, Presentations, Workflow Admission Rules DACR/NACR Reference Sheets and Checklist Common Night Float Issues (Falls, Hyperglycemia, CP, SOB) Radiology Eckel/Nephrology and Electrolytes Hellerstein/Cardiology and CICU Pulmonology/MICU Rheumatology Ratnoff and Weisman/Hematology and Oncology Carpenter/ID Dworken/GI Endocrinology and DKA Palliative Care and End of Life Toxicology Procedures Can I add that on? Best On Call Food Options Common Numbers VA and UH Numbers 004 Welcome to Case Western Internal Medicine. We’re glad you’re here. A hallmark of this residency program is continuous improvement. From Dr. Salata, Dr. Bonomo, and Dr. Armitage on down, we’re a great place which is always striving to be better. This book is an effort in that spirit, and it represents a first attempt to give interns a guide in practicing medicine at Case Medical Center (UH) and the Wade Park VA. This is not meant as a reference book (the Oxford manuals, Pocket Medicine, and Washington Manual are detailed references and there is no need to repeat their work). This book attempts to connect the most common issues on ward and ICU medicine with the nuances of how to make things happen for your patients at UH and the VA. This guide is meant to be an evolving document. As such, your recommendations are vital to maximizing its utility. If you see something wrong, let us know. If something should be added or removed, we would love your suggestions. To make a suggestion, email [email protected] with the subject: “Intern Book.” Lastly, while this book is meant to help guide you through some of the most common issues in ward medicine, it is no replacement for talking through an issue with a senior resident. At UH there is always a DACR, MICU and CICU resident, and usually your senior resident in house during the day. At night, the NACR, MICU, and CICU residents are always around as well. At the VA, there is always a MICU resident, cardiology resident, and at least 1 senior ward or night float resident. We love looking at ECGs, calculating acid/base, and even interpreting ANA panels. Once again, welcome and good luck. This is a program we love, and we’re glad you’re a part of it now. Sincerely, The Case Western Internal Medicine Senior Residents Contributors: Dhruti Chen Bryan Hambley Patrick Koo Katie Linder Shiv Madan Greg Nizialek Andreea Popa Nathan Stehouwer Jason Tuckerman Special thanks to all the individuals who reviewed sections of this book, including Cassie Kovach, Nathan Summers, Prashanth Thakker, Carine BouAbboud, Jacob Sadik, Jack Hornick, Peter Volpe, Megan Chan, Akriti Khanna, Akiva Diamond, Amanda Pensiero, Ruchi Shah, Ashley Wentworth, Paul Lin, and Will Hannah 005 2015-2016 Block Schedule Block Block 1A Block 1B Block 2A Block 2B Block 3A Block 3B Block 4A Block 4B Block 5A Block 5B Block 6A Block 6B Block 7A Block 7B Block 8A Block 8B Block 9A Block 9B Block 10A Block 10B Block 11A Block 11B Block 12A Block 12B Block 13A Block 13B Block Zero Intern July1-July 12 July 13-July 26 July 27-Aug 9 Aug 10-Aug 23 Aug 24-Sept 6 Sept 7-Sept 20 Sept 21-Oct 4 Oct 5-Oct 18 Oct 19-Nov 1 Nov 2-Nov15 Nov 16-Nov 29 Nov 30-Dec 13 Dec 14- Dec 27 Dec 28-Jan 10 Jan 11-Jan 24 Jan 25-Feb 7 Feb 8-Feb 21 Feb 22-Mar 6 Mar 7-Mar 20 Mar 21-Apr 3 Apr 4-Apr 17 Apr 18-May 1 May 2-May 15 May 16-May 29 May 30-June 12 June 13-June 23 June 24-June 30(OFF!!!) Holidays: Thanksgiving: Nov 26-29 (Thur-Sun) Christmas Dec 24-27 (Thur-Sun) New Years Dec 31-Jan 3 (Thur-Sun) Resident July 1-July14 July 15-July 28 July 29-Aug 11 Aug 12-Aug25 Aug 26-Sept 8 Sept 9-Sept 22 Sept 23-Oct 6 Oct 7-Oct 20 Oct 21-Nov 3 Nov 4-Nov 17 Nov 18-Dec 1 Dec 2- Dec 15 Dec 16-Dec 30 Dec 31-Jan 12 Jan 13-Jan 26 Jan 27-Feb 9 Feb 10-Feb 23 Feb 24-Mar 8 Mar 9-Mar 22 Mar 23-Apr 5 Apr 6-Apr 19 Apr 20-May 3 May 4-May 17 May 18-May 31 June 1-June 14 June 15-June 30 - *Note: Block 7B senior residents switch on Thur Dec 31st rather than Wed Dec 30th to fit with the holiday schedule. 006 Annual Residency Calendar July PGY-3’s: Start Your FCVS/Ohio/DEA Credentialling (must have Step 3 score) August Fellowship interviews (Late Aug-Early Nov) September Grand Rounds begins weekly Agre Society begins monthly (great food, friends, and some of the most outstanding researchers at Case Western) Intraining Exam October Interview Season Begins- Monday and Thursday Noon Lunches@ UHCMC and Dinners Sunday and Wednesday November Thanksgiving Holiday December Recruitment continues- Noon Lunches@ UHCMC and Dinners Fellowship Match Day (One of our biggest celebrations of the year) Christmas and New Years Holidays January Recruitment continues- Noon Lunches@ UHCMC and Dinners February Morale Week March Residency Match Results May Department of Medicine Research Day Bronson’s Day (interns go to a daytime Indians game) Housestaff Spring Dinner- 4TH Thursday of the Month June Future PGY 3 and PGY 2 Retreat Spring Picnic-First Thursday of the month. New Intern Orientation ERAS Fellowship Application process opens Block Zero: Last week in June. Vacation for outgoing interns, required coverage for PGY-2s and PGY-3s. 007 Sending Pages At UH: 1. Dial “222” 2. Wait for long beep, enter 5 digit pager number 3. Wait for a series of beeps, then enter your extension, followed by a “*” and then your pager number (the * and your pager tells the other team it’s a physician calling, and they answer quicker) 4. Wait for short beeps, and then hang up. If you make a mistake when entering your extension you enter you can hit “*” three times and start over. From outside the hospital including the VA: 216-207-7244; then follow the above directions. At the VA: -VA pagers are a 4 digit number. Some consult services (ID, surgery services…) have a set VA pager, others have a UH pager which may alternate with the resident/fellow on the service. 1. To page a VA pager, dial 9-440-562-xxxx (enter the 4 digit pager for the xxxx) 2. Enter your number followed by * and then your pager, followed by # 3. If you’re paging a UH pager, it’s 9-207-7244 as above, then the 5 digit UH pager followed by the same system as above. Even when paging a UH pager, if you enter your 4 digit extension they’ll know it’s a VA number you’re paging them to. To find out who is on call - Go to the VA intranet homepage, select Clinical References -> On-call schedule - https://vaww.v10.r03.portal.va.gov/sites/cleveland/oncalls/default.aspx Save these numbers to your phone: Answering pages at UH: 216-844-5344 then the extension you were paged to. This allows you to bypass the operator. Answering pages at the VA: (216)791-3800 then enter the 4 digit extension you were paged to. Paging a UH pager: (216)-207-7244 For a frequently updated google doc of UH pagers and extensions tinyurl.com/uhpagers is a document created by a neurology resident. Usually faster than calling the floor or operator, and common consult pagers are usually up to date (however services that change residents/fellows daily will still need to be found through the operator). The VA intranet is useful as well, as your resident how to log onto it. 008 Basic Tips and Tricks at the VA Noon conferences that have food (subject to change!) Monday, Thursday, Friday (Tuesday = Grand Rounds teleconferenced from UH, Wednesday = VA M&M) Getting blood draws urgently: PCU (2D) nurses can draw labs. 4a and 4b: “Labs on demand” order is how to get urgent labs drawn. This includes blood cultures. *You cannot order “timed” labs for non pre-scheduled draw times. If you need something drawn at 1am, you have to have night float intern order labs on demand at midnight. CPRS note writing shortcuts Getting labs and vitals: Templates Objects Wajeehs multi-use objects For labs not included in WMUO, you can copy-paste them. Coversheetbottom L corner Recent Lab Results double click highlight control+C (right click will not do anything) control +v in your note. Forced note templates: H&Ps and progress notes have required boxes. Some of them are actually not required to start the note fully. You can type a few letters to make the box happy and then submit. *Save without signature is a good way to start work and then return to finish later!* Filtering notes: select “all signed notes”. Two methods: Highlight medicine notes: Right click custom view bottom box “where either of” [x]title [x]subject contain: “medicine” Show all filtered notes at once (or find notes from another service): select “all signed notes”. A top box will appear with titles/dates of notes. You can sort by note title, and therefore find all the Cardiothoracic notes, etc. once you have created your medicine filter, you can see all the medicine notes only in that box. If you right click again and choose a new date range it’ll show you unfiltered notes and you can look at that top box and sort by alphabetical note title. Add a printer: The first time you sign on to a computer you have to install the printer for your account on that computer. StartSettingsprinters and faxesadd printer connect to this printer \\vhaclefpc1\cle-medw## (number will be labeled on the printer) PARKING You can park in both lots for free. If you want to park in the visitors’ lot, you “have to” get a parking pass from the police office, but they usually only check in the mornings during weekdays (ie. Before 9am). If you want to park in the employee lot across the street from E105 at a time other than in the morning, then you need to get a swipe card. In the mornings, the gate arms are always up. In the visitors lot, must park on the roof (ensures our patients have covered parking). 009 Inpatient Ordering C Diff Laboratory Quick Orders… -> Inpatient Labs -> All other inpatients -> Clostridium Difficile Ordering cytology (ie. On pleural fluid) Laboratory Quick Orders… -> Pathology Specimen Orders (under Anatomic Pathology) -> Non GYN Cytopathology -> Cytology Non Gyn Fluids Consulting Pharmacy to manage the Vanc levels - Consults -> Standard Consults -> Wade Park Consults -> Inpatient -> W Pharmacy Consults Inpt -> W Pharmacy Inpt Type and Screen - Go through the menu as if you are ordering blood, but don’t actually order blood, only select the type and screen. Suicide precaution Add new order -> suicide/hostile behavior precautions Outpatient Ordering Outpatient labs to be done in a future date Laboratory Quick Orders… -> Outpatient Labs. Select the appropriate labs. Scheduling an appointment for your patient in the future for patient you didn’t see today From CPRS, go to Tools -> CMT Task Tracker. The first time you do this, you might have to get authorization. Select the patient and attention the secretary for your color team in the comments section. Scheduling an appointment/checking out patients you see today. Webpage to see the status of your patient, ie. If they have been checked in or not. Also, the webpage to check out a patient when you are finished and to schedule a f/u appointment. 010 https://vhacleapp3.v10.med.va.gov/Cleveland/PatientAppointment/Doctor.aspx Alternatively, you can go to Tools -> More… -> Patient Appt Check-In To mail a letter to your patients with results Normally you would mail your patients a letter with results if the results are normal and do not warrant a telephone call. Create a new note called: “PATIENT RESULTS LETTER” and select which lab results you want to mail. When you sign the note, it will automatically print and get mailed to the patient. Renal duplex Consults-> wade park -> surgery -> vascular lab -> click continue -> select renal duplex *similar format for other vascular labs studies To forward your alerts to someone - To forward individually, just click on the alerts and select forward If you are going to be away from the VA and want all alerts automatically forwarded, go to select Tools menu -> Options -> Notifications tab -> Surrogate Settings button 011 Admission Orders UH: 1. First, if the patient not yet listed as on the floor, change the category of orders to “Pre-Admit on Hold” (a drop down option under ‘session type’ once you enter the order screen). 2. Start with the “Admission Order Set CMC”. This will have your basic admission dx, DVT ppx (if desired), vitals, diet, and even IVF and labs if you prefer to place them within the order set. If you’re entering as pre-admit, click the box telling the RN to release the orders on arrival to the floor. 3. Complete the medication reconciliation. There is no substitute for talking with the patient or their family. Doing this right and entering orders through this may take some time, but getting this right on admission will make discharging much easier. 4. Order any additional medications and imaging you want for your patient. 5. Labs can be ordered to recur daily by clicking the “Repeat” tab in the bottom left and next to the ‘floor to collect’ tab. If there’s a central line, including PICC and Mediport, it’s “Floor to collect first AM draw”, if no central line then it’s “Lab to Collect.” For “Range of Repetition” usually start with 5 or 6 days (if your patient is in house longer, they may no longer need daily labs). Remember not every patient needs daily labs, and many labs (coags, LFTs) are rarely needed on a daily basis. VA: 1. The main difference at the VA is that there are many more admission order sets. Some work for all patients, some are specific (alcohol withdrawal, NSTEMI…). Talk with your senior about which order set fits your patient. 2. Reconcile home meds. This is much easier at the VA, highlight the home meds you want to continue inpatient and then select the “transfer to inpatient” option. 3. Other orders: imaging, diet, new meds for their reason for hospitalization. 4. Remember, if you want to draw troponins to rule out MI in your patient, you need to call 5573 and ensure they are going to a PCU bed. 4B may soon house a few low risk CP patients and draw troponins. When that occurs, if a troponin returns positive the patient should be transferred to the PCU. If you’re concerned enough to have the patient on a heparin drip, always send them to the PCU. The History and Physical Whether at the VA or UH, your patient needs an HPI that accurately assesses their history and why they came to the hospital, with a clear plan on what your team will do for the patient. 1) A History of the reason the patient came to the hospital. Many residents use the first sentence to include important past medical history, but don’t feel obliged to include every detail here (that will come later). If the patient is here for chest pain, you can tell us “A 54 year old man with PMH of DM II, CAS, LAD PCI x2, who presents with exertional chest pain.” Then go in to the patient’s description of the pain. Pick your approach, “FAR COLDER” is one (Frequency, Associated symp, Radiation, Character, Onset, Location, 012 Duration, Exacerbating, Relieving). After you describe the chief complaint, you’ll have some suspicions. End the HPI by asking the patient some guided questions (did this happen before your last heart attack? Did you have leg pain and swelling prior to the chest pain and shortness of breath?...). Other residents should have an idea of your differential diagnosis based upon the questions you ask. 2)Past Med Hx/Surg Hx 3)Meds (Can cut and paste from your carefully done medication reconciliation) 4)Review of systems (often covered in HPI, add anything else here then say 12 point ROS complete for the bean counters) 5)Social: smoking/drugs/sexual/living situation/etoh is a start, add add’l pertinent info 6)Allergies 7)Vitals and Physical Exam 8)Labs/Imaging/Studies 9)Assessment and Plan: First give us your differential for the main chief complaint. Then make a problem based plan. If they are here for chest pain start with that. If they have diabetes and their insulin will need adjusted while NPO for a cath, add that as another problem. Chronic issues which are not active can be brief. 10)End every note with prophylaxis and code status (if DNR, ensure this order was entered into the EMR, at the VA this requires a “DNR Note”) Oral Presentations: -For the initial HPI, be able to talk fluidly about why the patient is here and describe their chief complaint. It’s fine to read their history/meds… -For the regular morning rounds, have vitals (we need numbers, not ‘stable’), labs if they are back, and all study results and consult recs from the previous day. Start with overnight events and vitals, quickly hit your exam (pertinents and anything that changed). Your assessment is a synthesis of all the information to describe what you think is causing the patient’s difficulties. Then move quickly to the plan. We’re a program based on autonomy, have a plan for the day and if it makes sense for your patient that’s usually what we’ll do. -We are not a malignant program. Rounds are not about pimping on random facts. The most important thing is to be able to enter a discussion about what is happening with your patient and the best next step for their care. Progress Notes In the era of duty hours, almost every hospital has a nightfloat based system. These physicians do not know your patients. Think of your progress notes as updates to the nightfloat about what happened to your patient that day and what you’re actively doing. SOAP S: subjective, update on chief complaint and tell us about any new complaints O: Vitals, then exam, then labs/imaging/culture data/other studies. Old imaging reports don’t need listed on every progress note. A/P: Assessment (first line is the identifier, then paragraph about where you are with diagnostic and treatment plan for the patient’s chief complaint). The last sentence or two of your assessment should start with the word “Today” and clearly tell covering 013 physicians ‘Today Mr Jones had a coronary angiogram with PCI to his left circ” or “a liver biopsy.” If a plan is in place for tomorrow (heart cath?) say it here. Keeping this format makes it easier for the covering team overnight if your patient is crashing, they can quickly discover if your patient had a procedure that may drastically alter the differential (post cath tamponade? Post liver biopsy hemorrhage....). The plan is again problem based. Some residents like to keep it updated with every detail for every problem (even non active problems). Others focus on a short description of changes and progress. Both approaches are fine. The most important thing is to ensure your plan is up to date. Don’t be the resident that describes the patient as on day 2 of vancomycin for 3 straight days, or anticipates a renal biopsy which happened 4 days ago. The last line of every progress note should be the code status (again, if DNR or DNI, ensure this order has been placed). Discharge Tips 1. Do the med rec the day before you plan discharge, that way you can discuss medications on rounds and address any issues. When you preround on the patient the day of planned discharge, ask if they need any refills and what pharmacy they want you to e-script it to. Asking this preemptively will save you from going back multiple times to send another script. 2. Start discharge planning day 1. 3. Plan appropriate follow up with primary care, and if a specific specialty follow up is needed due to issues during the hospitalization (such as Rheum for new SLE diagnosis) make that f/u as well. UH: If you order “Physician Appointment Post Discharge” 1-2 business days prior to discharge, staff will make these appointments for you at UH, and even add them to the discharge profile. VA: Goes through the outpatient consults tabs. 4. Discharge Med Rec UH: the med rec is a program through the med tabs. VA: you need to adjust your patient’s outpatient medication list to what you’d like it to be on homegoing (add any new inpatient meds you’d like the patient to continue). Then use the CPRS ‘Anticipated Discharge’ note to let pharmacy know you’re planning on discharging the patient and to take a look at your med list. They’ll frequently call with issues (if a med isn’t available, interacts with another med…). Get this in and then give them an hour. After they say they’re good with it you can move on to the discharge instructions. 5. Discharge Instructions UH: The Discharge Profile is where you give diet recs, plan PICC line care, list follow up. If the patient will need facility placement or home care, this is where those orders go. VA: The Discharge Instructions note is where the analogous guidance goes. 6. Discharge Summary 014 UH: The discharge summary is a type of note, and will include some prepopulated information along with a text box for your summary. VA: The discharge summary is a special note that appears in a different tab. Some components are prepopulated, but the general idea is the same. As briefly as possible you want to communicate to the outpatient physician why the patient came, what you did, and what you learned. In simple COPD/atypical chest pain type admissions this can be very brief, as little as 2-3 sentences. For patients with more issues it will be longer, but remember you don’t have to communicate every wrong idea you had or study you ordered, use the information you now know to judge what is pertinent for the outpatient team to know. A quick email to the PCP is always helpful. All antibiotics should have stop dates. As a rule discharge summaries done the day of discharge take half the time because all the information is fresh in your mind. There are lots of dispo issues which are best learned in person from your senior resident. Ask them, they’ve done it before and can help save you time. “COLD SAND: AM: Consults Orders Labs Discharges Daily workflow PM: Signout AM Labs Note Diet Tips for an Effective Night Float Signout A good signout should be concise, include only pertinent data, and give a covering resident a snapshot of the patient’s current clinical status. 1.) Basics that should be included: a. Identifying information: Name, room, MRN, Age b. Diagnosis (or working ddx), Pertinent PMHx c. Brief summary (keep it concise) d. Tasks for overnight, pertinent issues, guidance for foreseeable situations e. Is the patient SICK, ICU aware, etc. 2.) Be specific and include parameters: a. Rather than… follow up on In/Outs at 9pm, give 40mg IV Lasix if < net 500cc b. Rather than… transfuse if Hb is low Give 2units pRBCs for Hb<7 3.) Try to think ahead about pertinent possible issues: a. Include recent procedures and any possible adverse outcomes. Eg, ERCP today, please assess if abdominal pain for post-ERCP pancreatitis. 015 b. Include appropriate antibiotic coverage if you are watching for an infection. Eg, Concerned for HCAP. If febrile, get blood cultures, CXR and start vanc and zosyn. c. Include things to avoid! Eg, Avoid benzos…Don’t reculture if febrile…Don’t draw troponins. 4.) Pertinent FYIs: a. Include FYIs that could be useful. Eg, Neuro exams if abnormal…Pt has history of HIT… If MICU is aware of patient, may crash Ways to minimize calls for your peers: - Don’t forget to update the diet orders if necessary before leaving. - Include PRN orders for medications (anti-hypertensives, pain meds, etc) when you admit a patient - Tell the patient in advance if you are holding/changing home medications. This upsets patients and often prompts calls to the covering resident. - Don’t forget bowel regimens for patients getting narcotics. 3am calls for constipation happen! - Double check orders are in! If you ask them to follow up on an evening RFP, make sure it’s ordered. 016 Admission Rules • • • • • Long call – 3 patients by 7 PM • Only 1 after 6 PM, 2 after 5 PM Medium call – 2 patients by 4 PM Short Call: • UH: 2 Patients (nightfloat admission or ICU transfer) by noon • VA: 2 Patients (nightfloat or ICU transfer) by 1PM Cycle: Long Medium Short HAPPY! UH: • • • • • • VA: • • 10 patient cap per intern on all UH ward rotations EXCEPT Ratnoff and Weisman which cap at 8 (rolling cap, meaning an afternoon discharge opens up a long or medium admission slot) Short call day will cap at 8 (based on number of patients you start with in AM; not rolling). AI/intern pair cap at 10. Teams with 2 Residents: AI/Intern or Intern/Intern paired on same call schedule cap at 12, except Ratnoff/Weisman where it’s 10. With 1 Senior Resident: AI/Intern Pair and Intern/Intern Pair are capped at 10 and 8 (no increase) Cap = 8 patients per intern all days, Rolling Cap for Long/Medium AI/Intern Pair and Intern/Intern Pair cap at 10 (team cap=20) Special Circumstances • Hellerstein, Ratnoff, and Weisman Short will only get 1 patient • No Eckel Short Admissions • No team gets weekend short call admissions • AIs can get new admissions on short call (and increase long call to 4) • 2 senior time in early months may increase team cap. *During busy periods or when your team’s attending wants to admit a specific patient to the team, senior residents should be open to “flexing” on these patients when their team is capped. It’s paid, it helps the nightfloat, and it keeps patients on the team that will provide the best care. A win-win-win. Bouncebacks: Patients do better on teams that know them. Bouncebacks go by team, even if the intern or resident who worked with them initially if off. If a patient returns within 48 hours of discharge or MICU transfer, the patient will be a bounceback to the team and does not count as a new admission. These patients are often our sickest and keeping them on the same team is a top priority in order to improve the quality of their care. 017 DACR/NACR Reference Medical Nurse Practitioners (35642): • Preferred Patient: Private pts, elderly with placement/social issues or those many non-specific, complex general medical problems. • No ACS rule outs, but syncope on tele is ok. No sickle cell patients or patients that will need procedures • 1st priority for early admissions, patients must be on the floor by 5pm • Have a staff cap of 18 weekdays, 15 weekends. • On Saturday and Sunday only take nightfloat admissions. Sunday is off for NP’s but covered by hospitalist-will take night float admits • Can take ICU transfers that are non-tele Fang Service [37566] : • Moonlighting fellows overnight and during the weekend- if they are established patients of a heart failure attending or Dr. Effron they should be admitted by Fang or go to their service in the morning. Hospitalist B pager 36387 and C pager 37166 and D pager 32508: • Patients without complex social issues and quick turnover. No PRIVATES. • They have a cap of 12. One pt after 5 and none after 6. • Cannot take ICU Transfers that have been in the unit >48 hours. • Can take non-complicated sickle cell patients NOT ON SEIDMAN. If it is a busy heme-onc night, can put sickle cell on Tower with plan to give to Hospitalists in AM. Berger Team pager 36599: • Heme-onc pts with less complex issues. • Can admit NF or new patients. Evening hospitalist will admit new. Evening and overnight coverage may be increasing this year… Medicine Teams: • Naff LK 20/Wearn LK 20 -Gen med of all varieties. • Dworken LK55 -GI cases (luminal); Take established liver patients to a cap of 4 IF approved by hepatologist who will be primary attending on record Carpenter Tower 8 -All HIV pts should be on Carpenter – if pt has HIV+ESRD, use your judgment • Eckel LK 50 -Chronic ESRD on dialysis (if Eckel full, try to flex and put on the team the next day); -Pts with ARF in ICU followed by renal consult should go to other teams. -Family Medicine + ESRD go to Eckel -- no exceptions • Ratnoff (S3) /Weisman (S4) -Pts with known heme/onc disease followed in SCC. Pts with newly diagnosed cancer with bx proven diagnosis. -Some sickle cell pts can go to Gen Med or Hospitalists if Ratnoff/Weisman is fullneed to ask for beds on Tower/LK when this happens 018 -Bone Marrow Transplant pts go to BMT service (call the fellow 31252) during the day; staff patients overnight with the fellow • Geriatrics -Cap of 8, max of 3 new patients per day -Target admits are geriatric disorders: falls, polypharmacy, dementia related admissions • Hellerstein T5 -All patients with a UH cardiologist and a cardiac issue go to Hellerstein -Chest Pain, HF patients, CICU transfers; avoid patients with complicated medical issues who just happen to need telemetry RULES FOR OTHER SERVICES: Family Medicine (35111): Ask ED to contact FM for all Bolwell FM patients. We should not be giving them complex cardiac patients or any complex patient that is not a Bolwell pt. - When they are full, NF admits the overflow and then these pts should go to Family Medicine in the morning. Need to call in the morning and see if Family Medicine can take their patients back. - Generally non-Bolwell FP are to go to the Hospitalist service or appropriate service - All ESRD (even FP) go to Eckel For the services below, if the patient truly belongs on their service (the main issue is neuro or surgical or orthopedic), repeat after me, “We will be happy to take the patient as long as the ATTENDING does not want to accept the patient.” – THEY HAVE TO CALL THE ATTENDING AND THE ATTENDING HAS TO REFUSE BEFORE WE ACCEPT. Their note should specify the name of the attending with whom they spoke. Neurology: - Insist that all seizures be seen by neurology before assignment made in ED Transplant Surgery Day 38447 or Night/Weekend 31330: - All pts with kidney transplant <1 month MUST go to transplant surgery - All pts with kidney transplant <1 year, pancreas, liver transplant should go to transplant surgery service, on a case-by-case basis at discretion of IM transplant attending (if the patient is on more than steroids for immunosuppression, they should go to transplant medicine) - Always call the IM transplant attending if there is a question- they make the call General Surgery: - Insist that all SBO and other surgical cases be seen by surgery in ED before assignment is made – these should go to surgery. If resident refuses, we will take the patient if their ATTENDING also refuses. Orthopedic Surgery: - If pt has orthopedic issue + complex medical issues (e.g. DKA, COPD exacerbation) that would otherwise be admitted to medicine, then admit to medicine with ortho consult - If orthopedic issues but stable medical issues, then admit to ortho, but medicine consult manages all medical issues – see them for “co-management” and see them in a timely fashion 019 Pregnant patients: - Pt < 20 weeks – admit to medicine - Pt > 20 weeks – admit to OB/GYN EMERGENCY DEPARTMENT ISSUES: - Call admitting (72400) to coordinate proper bed assignments based on geographic localization - Pts can be moved to floor without assignment, pts can be assigned without a bed - Check on ED board often - If a pt is a Vet and wants to go to VA, call VA transfer center during day and M.O.D. (x4433) at night MEDICINE CONSULT ISSUES: - When a consult is called overnight, see the pt in a timely fashion and leave at least a preliminary note (‘full consult to follow’) - Ortho (or any service) does not need to have question, we co-manage medical issues & enter relevant orders (same for GU, etc.) - Pager 31067 is the Code White Nurse- please respond immediately to all level 2 code whites Admitting: 26054, 72400 Use the phone to keep in contact with admitting at all times: Geo LOC! ER: 43722; 48330 Medical NP Pager: 35642 Medical NP #s: 28418, 28417 Fang pager: 37566 Berger pager: 36599 CHARGE: 32575 CCLHD: 33116 ALHD: 37436 Family Medicine Pager: 35111 UH Chief: p31250; Phone 43621 Dr Armitage: p31552 020 NACR AM Checklist Resident NF Checklist: Run list with NF team Get updated list from NACR (do not use your previous version) Assign all housestaff patients and highlight or cross out patient when report given Follow-up with Chief to ensure Fang patients have not been reassigned to Hellerstein Run list with NACR to ensure all housestaff patients assigned NACR Checklist: 5AM: obtain intern census from NF interns and write on automated board printout Look on amion to see if any short call Med/Peds interns have clinic and cross off of automated board (cannot get new patients) Copy patients who have not arrived to hospital (from OSH) to book but take off NACR list Run list with NF team twice Print out updated list (2 copies for NF residents, 2 copies for Chief) Make sure book is updated with all overnight admissions and color in the box for patients who have been assigned a team. Leave OSH transfers who have not arrive uncolored (to be assigned when they arrive) Run list with NF residents to ensure all housestaff patients have been assigned Add team pagers to the NACR List At 8:00 am, the hospitalist will call you to discuss their patients. Write the assignments (B, C, D) next to hospitalist on the NACR sheet Copy all housestaff assignments to today’s automated board Fax yesterday’s automated board and today’s NACR sheet to all floors When you signout to DACR, make sure they know about new flex patients Chief Checklist: Run list twice with team Highlight list for MNP and Berger Call Fang to ask about admissions. If they are full, assign to Hellerstein and update NACR and resident NFs If a renal transplant patient was admitted, contact tx team If liver patient admitted to Dworken, make sure liver attending accepts Add patients to Flex board Add patients to each team list Go over H&P with medical student 021 NIGHT FLOAT ISSUES Congratulations! You’re now on night float (or as we like to think of it, the Wild West of medicine). You’ll betaking care of 4-5 medicine teams with patients, who will have plenty of issues in the middle of the night. We’ve tried to compile some of the more common calls you might get in order to make things a little easier. Don’t forget the NACR or PGY-2 NF are there for assistance. A fundamental rule is that if you see a patient or change management in a meaningful way, you should document your reasoning in a clinical event note. This will be immensely helpful to the day team. Logistics - Hours 7p-7a, There will be 2 NF Residents and the NACR (UH) or One NF Resident (VA) - Meet in Blue team room (VA) or Tower 5 (UH) - Signout at 7p and then throughout the night depending on when Long Call finishes. - Up to you how to split the teams. Generally for a two person NF team, a good split would be Lakeside (Wearn, Naff, Dworkin, Eckle, Geri) vs. Seidman/Tower (Ratnoff, Berger, Weissman, Hellerstein, Carpenter). - You *may* be called to admit patients on busy nights. General Suggestions on surviving NF - Biggest issue is to keep organized. Up to you what system helps you to keep organized. - Remember to get your senior’s contact info. Don’t hesitate to contact them if you have questions or feel you need more help! - Sunday nights there should be pizza in the resident lounge (Lakeside 6th floor) - In any emergency, first thing to ask is VITAL SIGNS. They are vital for a reason. This will tell you if the situation is urgent and help direct your next steps of action. - Help your colleagues get out on time. If your colleagues are swamped, see if, for example, they can sign out the team to you, so they can just focus on their new patients. “Mr. A is acting altered…” Altered mental status is one of the most common reasons you may be called overnight. The key to figuring out what to do about it is to figure out the most likely cause (or causes!) of AMS. Vital signs first, then go through an approach. We have found “TIPSAEIOU” to be a helpful mnemonic, but feel free to use your own. 022 T - trauma, toxins I - insulin (hypo- or hyperglycemia) P - psychiatric, polypharmacy, pain meds S - stroke, subdural hematoma, seizures A - alcohol E - electrolytes(sodium, calcium), encephalopathy (hepatic) I - infection O - oxygen (hypoxia, hypercapnea) U - uremia Given that these are your likely possibilities, consider obtaining the following: • POC blood glucose (the RN can do this for you) • arterial blood gas • neurologic exam • repeat labs including CBC, RFP, lactate (if you think this is indicated) • blood cultures (if you suspect infection as cause of decompensation) Ask yourself the following questions: • is the patient so altered that they cannot protect their airway? (if yes, call Code White and consider MICU transfer) • is the patient hemodynamically unstable? (if yes, call Code White and consider MICU transfer) • does the patient have new neurologic deficits? (if yes, call BAT team and neurology will come to your aid at UH). At the VA, activate stroke protocol in CPRS if concerned. • Has the patient had any medications recently that may cause alterations? • *BAT and Code White are at UH. At the VA you can call an MNR, but the most important thing at both hospitals is to talk with the night resident and ICU resident for the best next steps in caring for your patient. “Ms. B has a fever.” In any case of a new fever, it is important to consider infectious etiologies as well as any non- infectious causes of fever. Keep in mind: • fever is defined as a T of 38C over at least one hour, or T of 38.3C once. It is usually reasonable to recheck T in another hour Once patient is febrile, you should think to yourself - is this an infection? • at nighttime, it is SAFER to assume a fever is infectious. Day team can always narrow antibiotics! • however, if you feel strongly that this is a non-infectious fever (perhaps patient has another reason to have a fever, e.g. VTE, lymphoma and appears otherwise well) it is reasonable to check on the patient in another hour or so and make sure they are doing well • DO NOT give any antibiotics without collecting blood cultures (as well as urine and sputum if possible). If you can’t get access for blood cultures and are suspicious of infection, go ahead and treat. 023 • • • • • IF you choose to give antibiotics, start broad and the team can narrow later. If the patient is already on antibiotics, you can consider broadening the spectrum. Check med list if you’re concerned for NMS or serotonin syndrome. See neutropenic fever section in H/O chapter Always check allergies before new abx Treat fever with acetaminophen if patient is symptomatic OR if fever is dangerously high, e.g. >40C. “So Mr. C had a blood sugar of 450 on their bedtime blood glucose check; how much insulin do you want me to give?” Typically, patients with DM will have blood sugars checked before meals (for the sliding scale to be administered) and before bedtime. Since it is common to give patients less insulin on admission (in order to protect patients from hypoglycemia), patients will often have higher blood sugars while inpatient. All sliding scales at UH and the VA max out at 400. If a patient’s blood glucose is >400, the RN is asked to call the physician to verify dose. Keep in mind the greatest risk to your patients in the hospital is hypoglycemia, not hyperglycemia. For most type 2 diabetics who are getting ready for bed and not eating any more, they don’t need additional insulin for glucose <350 (they need the day team to titrate their long acting). If it’s >350, determine a single short acting dose based on the patient’s daytime use. Remember, sliding scale may grossly underdose a long term type 2 diabetic, but may overdose a type 1 diabetic. Know your patient. Don’t forget to tell the day team the readings so they can adjust the long acting. 024 “Ms. D is complaining of chest pain.” Chest pain is one of the most concerning calls you may get as a night float intern! The good news is that a good percentage of the chest pain that occurs in the hospital is non-cardiac. Regardless, the following steps should be taken to ensure you don’t miss anything: • collect a FULL set of vitals • ask the bedside RN to get a 12-lead ECG (this may have been done for you already) • obtain an old ECG (this can be done in physician portal tab on left under cardiovascular system or vista imaging by clicking the ECG tab, or can be done by looking in the paper chart) When you see the patient: • obtain a history of when symptoms started and with what activity; if patient was walking to the restroom when pain started, you may be more concerned than if patient was laying flat after eating. • find out if patient has ever had this pain before. Is this the pain they had that brought them to the hospital? • full cardiac exam INCLUDING cardiac auscultation, assessment of JVP, palpation of the chest wall If ECG or exam is concerning, discuss with NF senior or with the NACR; they can assist you in triaging the patient. You can send a troponin and an AMI panel if you have a suspicion that chest pain is cardiac. It will likely not influence your overall management since it will take time to return and since troponin will not increase after acute event for several hours. At the VA, you will have to move the patient to the PCU to trend troponins. (One time draw can be done by M&R RN or by labs on demand.) 4B and 5A may soon allow troponins and low risk chest pain. CARDIAC NON-CARDIAC stable angina acute coronary syndrome - unstable angina - NSTEMI - STEMI - Dissection - Pericarditis cardiac tamponade cardiac vasospasm musculoskeletal chest pain costochondritis GERD lung pathology - PNA - pleuritis - PE - Pneumothorax - Esoph Rupture 025 “Mr. E fell.” Falls are unfortunately more common in the hospital than we’d like them to be. When called to assess someone post-fall consider the following: • how did the fall happen? was it mechanical, or did patient have a seizure or a syncopal event? • did patient hit head? • did patient lose consciousness? • was patient on anticoagulation? Post-fall, it is appropriate to conduct a full neuro exam to assess for focal deficits. It is appropriate to get imaging of the head (non-contrast CT) if patient was on anticoagulation, if patient hit head, or if patient had loss of consciousness. The VA has a “Post Fall Assessment” note. At UH use a clinical event note. “Ms. H is feeling short of breath.” Acute shortness of breath is another complaint that is nerve-wracking to get in the middle of the night. First, get a full set of vitals. Is the patient subjectively short of breath, or are they actually desatting? The big 3 tests of dyspnea: ECG, ABG, and portable CXR. If patient is desatting, start oxygen: NC oxygen —> ventimask —> nonrebreather* —> NIPPV* —> intubation* Consider ICU transfer for starred options. Remember CPAP for hypoxia and BiPAP for hypercapnea (more complex than this, but beyond the scope of this book). Pulmonary causes of SOB: Pnthx, obstructive (COPD/Asthma/foreign body), Aspiration, Pulm HTN, ILD, Effusion, DAH, PE, PNA Cardiovascular causes of SOB: CHF, MI, tamponade/myopericarditis, arrhythmia Non-Cardio/Pulm causes: Anemia, metabolic acidosis, carboxy/sulph/met-Hgb, diaphragmatic paralysis (ALS?), Abdominal HTN. Additional tests to consider: CBC, RFP, D-dimer, CT PE, troponin, BNP “Mrs. F’s blood pressure is 201/130.” Hypertension can be either a primary problem mandating hospitalization or can be secondary to underlying medical conditions. Try to assess why your patient is acutely hypertensive. Is there a stimulus that can be treated (e.g. pain/discomfort, anxiety)? Did patient take AM antihypertensives or did they miss these medications 026 for some reason? Severe hypertension comes in 2 “flavors”: • HTN urgency: BP >180 systolic or >120 diastolic WITHOUT end organ damage • HTN emergency: BP >180 systolic or >120 diastolic with evidence of end organ damage. Examples of end organ damage might include papilledema, chest pain, troponin leak, dizziness, altered mental status. BP should be lowered no more than 25% acutely in order to maintain cerebral perfusion. Oral agents are appropriate to use in cases of hypertensive urgency, but not in hypertensive emergency. Commonly used one-time agents include: • hydralazine - arteriolar vasodilator, can be given q8h. Beware reflex tachycardia! Starting dose is often 10mg PO, but this is usually too little and dose can be increased to as high as 100mg PO tid. IV hydralazine is rarely indicated as it can cause precipitous drops in BP. • labetalol - mixed alpha/beta blocker. Start with 100mg PO • You can give patients their AM medications early if needed! Commonly used IV agents for HTN emergency include: • nitroglycerin • nitroprusside • nicardipine These agents are restricted to MICU/CICU and should not be started without appropriate level of care. Note at the VA patients need to be in the PCU for IV antihypertensive administration. “Mr. G is having a lot of pain and he doesn’t have anything ordered.” Often patients will have some PRN pain meds written but this isn’t enough to treat their acute pain. First, assess the patient’s pain. Is pain musculoskeletal? Is it neuropathic? Is it similar to pain that brought them in to the hospital? Sometimes team will try to restrict certain pain medications (particularly if concern for narcotic abuse) so check your signout to make sure that the team has not restricted your arsenal. 027 medication give for caution with dose acetaminophen mild pain liver dysfunction (2g daily max in cirrhosis, 3g daily max for normal liver function) 650mg PO q6h prn; 1g IV q12h prn (IV form available at VA only) ibuprofen (NSAIDs) mild to moderate pain, MSK pain renal or liver failure (could precipitate HRS), heart failure, GI bleeding 400-600mg PO q6h prn; consider prophy PPI ketorolac moderate pain, MSK pain GI bleeding. cannot use for >5 days and cannot use while other NSAID ordered. 30mg IV q6h (15mg for renal dosing); consider prophy PPI tramadol moderate pain Liver and renal failure 50mg PO q6h prn (q12h (contraindicated in Child C) for renal failure and cirrhosis oxycodone moderate to severe pain - 5mg PO q4-6h prn morphine severe pain renal failure (renally excreted) 2mg IV q4h prn, increase as tolerated dilaudid severe pain - start at 0.2-0.4mg IVPB q3h, increase as needed 028 Radiology Diagnostic Radiology The department of radiology performs a wide variety of studies such as radiographs, CTs, MRIs, ultrasounds, fluoroscopic studies, PET scans, and other nuclear medicine studies. Give radiology a clinical scenario or question and they will provide a more specific read. M-F 8am to 5pm studies will be read by the individual subdepartments within the department of radiology. After 5pm on weekdays and on weekends the in-house Junior Radiology resident (X-rays and CTs) on call can be reached at 32494 and the Senior Resident (Ultrasound and MRI) can be reached at 32495. At the VA, after hours radiology reads (after 5PM and on weekends) are available by calling Valor at 1 800-773-9812. The American College of Radiology maintains a large database of evidence based recommendations on the appropriateness of various diagnostic tests broken down by symptom. These can be found online at ACR.org, click the “Appropriateness Criteria” tab under “Quality and Safety.” Specific tips- Head imaging - Basic head CTs should be ordered without contrast. - Brain MRI’s are considerably more sensitive and specific for all types of brain pathology with the exception of acute hemorrhage. Specify your indication in orders as much as possible as the exact sequences run will be selected by a radiologist depending on the indication. In general, any evaluation of a mass requires Gadolinium contrast. Chest imaging - CT to exclude Pulmonary embolism requires IV contrast - CT of chest for other indications generally benefits from IV contrast, but the lung parenchyma can be evaluated for nodules and masses without should contrast be contraindicated. There are almost no indications for CT Chest requiring both with and without contrast. Abdominal imaging -Plain radiographs of the abdomen (KUBs) have limited sensitivity for many types of intraabdominal pathology and a negative KUB does not rule out serious intra abdominal pathology. Order erect views if you wish to exclude a large volume of free air. - IV contrast benefits most general CTs of the abdomen. Exceptions include evaluation of kidney stones and evaluation of intraabdominal or retroperitoneal hemorrhages. 029 - There are several dedicated CT studies of the abdomen including Triple phase liver, Triple phase kidney, and Triple phase adrenal CTs. These are special protocols to evaluate masses within these organs and should be specified if required. CT urograms are also dedicated CTs of the kidneys, ureters, and bladder that administer a higher dose of radiation and should be specified if required. - Oral contrast may be positive or negative contrast and is generally decided by the radiology department. If you have a strong preference for positive oral contrast, include this in the order. Oral contrast is useful for bowel pathology - MRI of the liver, pancreas, or kidneys should generally be performed with Gadolinium Contrast Caution with Contrast Contrast induced nephropathy- IV contrast used in diagnostic CTs, angiograms, and cardiac catheterizations can cause a generally reversible type of acute kidney injury referred to as contrast induced nephropathy. The largest risk factor for CIN is low GFR at the time of contrast administration. In patients with very low GFRs who are not on dialysis, IV contrast may not be appropriate. IV hydration for patients with borderline GFRs may reduce the risk of contrast induced nephropathy. Nephrogenic Systemic Fibrosis- IV gadolinum contrast used in diagnostic MRIs can cause a severe fibrosing disorder in patients with preexisting renal failure. While uncommon (~400 cases are reported in the literature) NSF is a life threatening condition. Gadolinum contrast should be avoided in patients with a GFR less than 30. If gadolinium is necessary in a patient with such a low GFR, dialysis should be considered within hours following imaging to reduce the risk of NSF (and done 3 straight days thereafter, discuss with nephrology before the MRI). Interventional Radiology (Specific for UH, some may apply to VA) The department of interventional radiology performs a wide variety of procedures using various methods of image guidance such as ultrasound, fluoroscopy, and CT. Procedures performed -Basic image guided procedures such as paracentesis, thoracentesis, and lumbar punctures -Ultrasound or CT guided biopsies, drain placements, nephrostomy tube placements/exchanges, and pleurx catheters. -Various vascular procedures such as IVC filter placements, vascular embolizations for GI or other bleeds, TIPS, etc. 030 -Vascular access such as temporary dialysis catheters, tunneled lines such as tunneled PICCs, dialysis catheters, hickman catheters, and mediports. At the VA tunneled lines are outsourced and require a travel consult. -Dedicated PICC nurses place PICC’s and Midline catheters, but not on weekends. Ordering procedures- At UH, for any questions regarding IR procedures from M-F 7am-5pm contact the interventional radiology nurse coordinator at ex 48290. After hours and on weekends the senior radiology resident on call can be reached at pgr 32495 and is the contact person for all interventional procedures. - Lumbar punctures, thoracentesis, and paracentesis orders can be found in the EMR- In the order, try to include whether the procedure is to be diagnostic (only a small amount of fluid to be removed for analysis) or therapeutic (a larger volume removed to relieve symptoms). - Specify the required laboratory studies as certain labs require specific collection methods. Flow cytometry, cytology, and pH for body fluids generally require special handling. - - The general order for most other IR procedures is the “Angio Consult for Body” order in UH Care - Include the specifics for exactly what procedure you wish performed in the special instructions section. Ex. Clarify the lesion you wish biopsied, the fluid collection you wish drained, or what size line you want placed. PICC’s and Midline catheters can be ordered in the EMR under the PICC Midline Placement CMC/Ahuja Order Set. Always order flushes for Midline/PICC. Procedures checklist- Depending on the procedure, IR will have certain preprocedural requirements. If you anticipate your patient will require a procedure done by IR the next morning this list can expedite the process and make sure the IR department will be able to attend to your patient. - - NPO after midnight- Many IR procedures are performed under conscious sedation using fentanyl and versed administered by the IR department requiring that the patient be NPO to reduce the risk of aspiration. If you anticipate your patient will require general anesthesia, arrangements will need to be made with the department of Anesthesia, which depending on the urgency, has taken up to several days to coordinate. INR and Platelet counts- In general, INR <1.7 and PLT >50,000 will be acceptable for any radiology based procedure, but the necessary levels are somewhat 031 - - - dependent on the attending radiologist performing the procedure and upon the specific bleeding risk of the procedure. Fresh Frozen Plasma or Platelets, ordered from the blood bank, may be required depending on these specifics. Often, these will be ordered by the primary team, but administered by the radiology department. Remember, patients who have an elevated INR due to Coumadin or other anticoagulation are at a higher bleeding risk than patients with liver disease causing an elevated INR. Talk with radiology, be sure to differentiate between Coumadin patients and cirrhosis to avoid unnecessary blood product exposure (they may still want FFP in cirrhosis for a para, and the team doing the procedure ultimately makes that call). Stopping Anticoagulants and Antiplatelets- Patients on warfarin with a therapeutic or elevated INR may require FFP prior to the procedure. Heparin drips and other IV anticoagulants will need to be stopped 4-6 hours prior to many procedures. Depending on the risk of the procedure, clopidogrel or newer oral anticoagulants may need to be stopped several days in advance of a nonurgent procedure. The VA often wants 5-7 days off aspirin/clopidogrel and urgent procedures may require attending to attending discussion. Consent- Consent will be obtained by the radiology department. If the patient is un-consentable, the radiology department will require contact information for the POA or next of kin. Providing this information in the order may spare you a phonecall. GFR/Renal Function Labs- Some Vascular procedures, such as IVC filter placements and GI bleed embolizations, involve the use of IV or arterial iodinated contrast. Head CT for Lumbar Punctures- In general the department of radiology will require a recent head CT before performing an LP on any patient with impaired mental status, focal neurological deficits, papilledema, new seizure, or impaired cellular immunity due to the risk of herniation. 032 Top 5 Eckel(Nephrology) Admissions Eckel Basics: -2 Residents, 4 Interns -Interns get happy day off For all admissions the first line of the assessment should be: “ESRD due to_________, on HD days, at location, via access (nephrologist is ___________, dry weight is ___________).” 1. Fever during dialysis/infection: Most likely etiologies of infection – sepsis from line infection!!! Must check all access sites, when they last had tunneled catheter replaced, etc. 1. Draw cultures peripherally and from dialysis access site (only dialysis RN can do this). 2. Other causes include pneumonia (HCAP), skin and soft tissue, joint, C diff, endocarditis. 3. Review recent blood and other cultures. MIC creep with vancomycin is real and may change the empiric gram positive coverage you start. Treatment: 1. Use IV antibiotics to cover gram positives for line infection, especially MRSA! 2. If patient has catheter and cultures return positive for pathogen, it must come out and have “line holiday” for two days prior to re-insertion of new catheter. 3. Culture results with CONS (coagulase neg staph) is often not a contaminant and must be treated though can often be treated with IV antibiotics and not require catheter change (talk with ID). 4. Staph and some other organisms require workup for endocarditis/seeding of other sites (TTE? TEE? MRI for back pain?). Staph aureus in the blood should have an ID consult. 5. ESRD Vanc dosing: 20mg/kg load followed by 10mg/kg after HD 6. ESRD Pip/tazo dosing: 2.25gm q8h for HCAP, 2.25gm q12h otherwise 2. Shortness of breath due to fluid overload: Most likely etiology of shortness of breath – fluid overload, interdialytic weight gain. You can check their weight after last dialysis session in dialysis sheets (call HD unit for this info) and compare to today’s weight. Most patients have a known “dry weight” (ask the patient, if they don’t know ask their HD center). Also consider other ddx including acute hypertensive urgency and flash pulmonary edema, CAD and ischemia (remember more than 25% of HD patients experience sudden cardiac death). 033 Treatment: if significant weight gain and symptoms, must get dialyzed to get fluid off. If they have access, call the HD unit (41585) or coordinating nurse (Melissa) to set up HD in the dialysis unit or in patient’s room if later in evening. If they don’t have access decide if it’s urgent (hypoxia, tachypnea…). If so, need to go to unit for access and HD. If not, IR in AM for temporary line (tunneled?) and HD after. -Few patients make enough urine for diuretics to give significant benefit, but ask them about urine output and you can try. If GFR<30 HCTZ doesn’t work. -Afterload reduction for HTN (hydralazine, ACE/ARB if ESRD with normal K) 3. Missed dialysis/hyperkalemia Most likely etiology of hyperkalemia – usually cause is ineffective elimination (in HD patients, missed/incomplete HD sessions) or excessive intake (dietary), sometimes medication induced (think ACEI, NSAIDs, Bactrim). Make sure sample is not hemolyzed (most common causes of hemolysis is drawing labs via small bore peripheral IV, traumatizing the cells)! You should be worried with K above 5.3, very worried if K>5.8 with ECG change (peaked T waves, small p waves, increased PR interval, and widening QRS from baseline). Notably, ECG changes are less sensitive in ESRD. Treatment: temporary measures including shifting potassium into cells (insulin/D50), stabilizing cardiac membraines (calcium gluconate or calcium choloride buy you 30-60 minutes). More long acting measures include elimination through hemodialysis (acutely, especially if ECG changes and high K) or kayexalate to bind potassium in GI tract (should be used for low levels of hyperkalemia without ECG changes if HD is not readily available). On Sundays, HD unit is closed and patients needing urgent HD need MICU tx. 4. No vascular access for HD Most likely etiology – patient had clotted graft/catheter. There are three types of HD access that we see primarily: 1) fistula (ideal, less complications, less likely to thrombose or get infected), 2) AV graft (artificial material is used to create access, higher risk of thrombosis and infection) 3) Central venous catheter with two lumens (tunneled catheters are used for long term access to reduce risk of infection, other complication includes stenosis and thrombosis). Treatment: determine when the access was last used, whether it is working at all (talk to the dialysis center nurse about this, they are immensely helpful!). Examine the fistula for thrill/bruit or aneurysm (which may need to be repaired). Imaging of AV graft to evaluate for thrombosis and declottication, vascular surgery usually does this (talk with vascular the day a nonfunctioning graft/fistula is admitted, in some cases time is essential). Remember it takes months for a fistula to become functional, plan for the interim as well. -At UH, Body Angiography Consult for IR for tunneled HD line. Tell them where you want it. 034 -At the VA, talk with IR, requires planning (and often begging). Tunneled lines are outsourced. -If it’s urgent, transfer to MICU at either VA or UH for line and HD. 5. Chest pain + ESRD Most likely etiology – just like in any other patient, you should be worried about MI, arrhythmia, PNA. But in ESRD patients, be more worried!! These patients have significantly higher cardiovascular mortality and any chest pain syndrome should be taken seriously. Get an ECG, CXR, troponin (if appropriate) and low threshold to monitor closely on telemetry. Remember ESRD doesn’t cause positive troponins, just lowers their clearance. See Cards section on chest pain for more details. Common ESRD inpatient problems/pages: Hypertension in AM before dialysis – Remember these patients are often fluid overloaded and have elevated BP at baseline. BP before dialysis days tends to be higher, you can look back at their prior admissions/notes and see the trend. Give the morning medications, make sure they are getting dialyzed early and having fluid removed. If in the interim BP is >200/100, use PO hydralazine or PO clonidine (caution with IV hydral for precipitous drops, if needed start with 5 IV). Make sure you follow up after giving the medications and re-assess the patient for symptoms. Hyperkalemia on AM labs – Is it real or hemolysis? How high is the potassium? Is it higher than 5.8-6.0? Get an ECG, follow up on next HD session and give calcium/gluconate, insulin/D50 and kayexalate if HD will not be done urgently. Place patient on telemetry. If there is urgent HD required, patient may need MICU transfer. Hypokalemia on AM labs in ESRD – Remember ESRD patients do not excrete potassium normally unless they make some amount of urine. So be wary of repleting K as you would in a patient with normal renal function. In general, if K>3.4, do nothing. If K<3.4 and patient known to have diarrheal illness, cardiac arrhythmia, etc then replete about half as much as you would for normal renal function and recheck! Remember, labs drawn in the hours after HD can show inaccurate hypokalemia as body reaches new equilibrium. Redraw >6 hours later to confirm a post-HD patient is truly hypokalemic. Unable to get AM labs – Many of our patients with ESRD have difficult vascular access from years of attempted access, inflammatory states leading to venous stenosis, fistulas on multiple extremities. If labs are not urgent and patient is stable, they can get labs when they go to dialysis unit. If urgent, consider arterial stick for full panel. If prolonged access issue, patient may need 035 PICC, but this should be discussed with nephrologist as it is placing them at higher risk for stenotic vessels which may limit future HD access (if you can get away with a midline instead of PICC, do it). Acute hypotension, bleeding, sepsis requiring fluid resuscitation – Patients with ESRD are used to large fluid shifts, however in setting of acute sepsis, large bleed or hypotension they may require IVF acutely. The major risk of IVF is pulmonary edema in this population. Start with small IVF bolus (500mL) and monitor clinical status closely, confirm code status (are they okay with intubation if needed), discuss whether they still make urine (and would respond to loop diuretic therapy). If blood product transfusion planned, try to coordinate during HD sessions. ELECTROLYTES Hypocalcemia: Long QT, wide QRS, parasthesia, confusion, tetany, seizures. Remember to correct for low albumin (add 0.8 to calcium for every 1 decrease in albumin below 4). Remember alkalosis causes calcium to bind with albumin, causing real hypocalcemia. Oral Replacement: Calcium Carbonate tablet 1250–2500 mg (500–1000 mg elemental calcium) PO TID–QID Recheck serum calcium or ionized serum calcium daily Parenteral(IV) Replacement: Calcium GLUCONATE Serum Ca(i) Level 0.85 – 1 < 0.85 • • • • • 2 grams Calcium Gluconate IV in 100 mL of D5W or NS over 1 hour 3 grams Calcium Gluconate IV in 100 mL of D5W or NS over 2 hours May repeat serum level 2 hours after the infusion complete. Repeat replacement boluses as needed. Maximum concentration: No maximum concentration; may be given undiluted in emergency situations Maximum infusion rate: Calcium Gluconate 200 mg/min; Calcium Chloride 100 mg/min (in emergency situations) Rapid calcium infusions may cause vasodilation, hypotension, bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. Extravasation of calcium can cause serious tissue irritation and necrosis. Immediately discontinue administration if observed. If hypocalcemia and hypomagnesemia coexist, magnesium should be corrected to avoid accumulation of calcium in muscle cells. 036 • Hyperphosphatemia should also be corrected prior to administering calcium Hypercalcemia: I Signs: "Stones, moans, groans, with psychic overtones" •Renal: polyuria (that’s why they’re always dehydrated), nephrolithiasis, renal failure •GI: nausea, vomiting, constipation •Neuro: weakness, confusion, coma •EKG: shortened QT II Mechanism: 1)increased bone resorption 2)increased GI absorption 3)decreased renal excretion. III Etiology: 1. Primary hyperparathyroidism: 85% adenoma, 14% hyperplasia, 1% carcinoma 2. Malignancy: PTHrP-mediated: especially with renal tumors and squamous cell carcinomas: lung, head/neck, esophageal, bladder, ovarian Osteoclast Activating Factor: multiple myeloma, lymphoma, leukemia, some solid tumor mets (e.g. breast cancer) 3. Granulomatous disease: sarcoidosis, fungal, TB (increased 25-OH Vit D) 4. Vitamin D toxicity 5. Milk-alkali syndrome 6. Thiazide diuretics 7. Hyperthyroidism (T3 increases osteoclast activity) 8. Adrenal Insufficiency (Addison’s) 9. Immobilization 10. Familial hypocalciuric hypercalcemia 11. Lithium 12. Estrogens and anti-estrogens 13. Aluminum intoxication IV: Workup 90% due to hyperparathyroidism or malignancy. Initial labs: Ca, Phos, albumin, ionized Ca, alkaline phosphatase, PTH. If PTH appropriate: send TSH, Vit D 1,25, Vit D 25, PTHrP, SPEP/UPEP, cancer screening, LDH, beta-2-microglobulin. If PTH inappropriate: it’s either primary hyperparathyroidism or FHH (urinary calcium can help dx the very rare FHH) V: Treatment 1. IVF volume resuscitation: at least 3-4L in first 24 hours 2. IV lasix after volume repleted (urine Na and Cl > 90). Keep I =O. 3. Calcitonin: 4-8u SQ/IM q6-12hr. Works within hours, but weak effect (1-3 037 mg/dL) that wanes after 2-3 days. 4. Pamidronate: 90mg IV over 24hr (for Ca>13.5) or zolindronic acid 4mg once. Treatment of choice in hypercalcemia of malignancy. Side effects include decreased Mg and phos and low grade temperature. 5. Caution with bisphosphonates in renal failure. -The cancer may be metastatic, but don’t determine your patient’s functional status until their calcium has normalized (they may be able to tolerate more aggressive therapy than you first think when they’re acutely hypercalcemic). Hypomagnesaemia: lethargy, confusion, arrhythmias Oral Replacement (may cause diarrhea): 1. Magnesium Oxide tablet 400–800 mg PO daily 2. Milk of Magnesium (magnesium hydroxide) 24% concentrate suspension10 mL = 1001 mg of elemental magnesium (82 mEq) Parenteral Replacement: Magnesium Sulfate Serum Level (mg/dL) 1 – 1.5 <1 2 gm Magnesium Sulfate IV in 100 mL of D5W or NS over 2 hours (2 gm =16.2 meq) 4 gm Magnesium Sulfate IV in 250 mL of D5W or NS over 4 hours (4gm = 32.4 meq) *** In patients with renal insufficiency (creatinine clearance < 50 mL/min) use 50% or less of the suggested dose. In patient with cardiac risks for arrhythmia, may be more aggressive (slight overcorrection safer than sustained level <1). • Oral therapy is not usually adequate to replace mag<1.5 mg/dL). • Serum magnesium concentrations may be elevated for 1-2 days following an infusion, because it can take up to 48 hours for the magnesium to fully redistribute into body tissues. • Serum magnesium levels correlate poorly with total body store Hypermagnesemia: 1.Rarely a clinical problem unless serum mag > 4mg/dL 2. Severe symptoms include: areflexia, hypotension, bradycardia, asystole, heart block 3. If severe, 1 amp calcium gluconate over 10 minutes. May need calcium gluconate infusion or HD depending on setting. -Remember at UH, RFP does not include a serum magnesium level (order separately, ok to add on) Hypophosphatemia: • Alcoholics and malnourished at risk. Also critically ill burn/sepsis/cirrhosis patients. Refeeding syndrome is when insulin shifts phos into cells. Hypophos is usually less clinically worrisome than other electrolyte disorders. Oral Replacement: 038 • • Neutraphos packet 1-2 PO TID–QID • K-Phos (250mg tab= 75mL solution) Parenteral Replacement: Serum Level (mg/dL) 1 – 1.9 SODIUM or POTASSIUM Phosphate 21 mmol SODIUM Phosphate IV in 250 mL of NS or D5W over 6 hours or 21 mmol POTASSIUM Phosphate IV in 250 mL of D5W or NS over 6 hours 30 mmol SODIUM Phosphate IV in 250 mL of NS or D5W over 8 hours or 30 mmol POTASSIUM Phosphate IV in 250 mL of D5W or NS over 8 h *** In patients with renal insufficiency (creatinine clearance < 50 mL/min) use <1 sodium phosphate and 50% or less of the suggested dose. Hyperphosphatemia: • Think: Renal failure, tumor lysis, iatrogenic replacement, rhabdo • Can cause calcifications if severe. • Treatment: CaCO3 (tums) 1000mg tid with meals or calcium acetate (PhosLo) 667mg tid with meals bind phos in the gut to prevent absorption. If calcium is low use sevelamer. Hypokalemia • Causes: Diarrhea, vomiting, alkalosis, renal losses (diuresis, mineralocorticoid excess, RTA I/2), hypomag • Look for EKG changes: T wave flattening, A fib, NSVT, U wave V4-6 • As above, supplement ESRD/CKD patients cautiously. Strategy: 1. Replete Mag first 2. Know how far you’re behind: Potassium Level (in meq/L) 2.0-2.5 2.5-3 3.0-3.5 3.5-4.0 mEq of repletion for a 0.1 increase in KCl 40-50 30 10-20 10 *Caution, levels within hours of dialysis may be falsely low while body equilibrates. -And if you’re continuing diuresis, they’ll continue to lose more. 3. Make a plan: The downside of PO is upset stomach (pills probably better tolerated than terrible tasting liquid/powder, though if they have an NG these are good options). The downside of IV is if given through a peripheral IV it’s painful, and must be given slowly regardless (10mEq per hour max through 039 peripheral, 20mEq max via central line) 4. Set a goal: >4.0 in a cardiac patient, >3.5 in noncardiac Hyperkalemia: See above (meds similar in ESRD/non ESRD). If DKA, see DKA-specific section 040 Cardiology Hellerstein The inpatient team that is staffed by a Cardiology attending. Most of the patients admitted to the service present with typical or atypical chest pain that physicians in the ED feel need to be ruled out for potential acute coronary syndrome. Other patient categories include heart failure exacerbations with fluid overload, valvular diseases (especially patients who are planning to undergo transcatheter aortic valve replacement), and those with heart rhythm disturbances like atrial fibrillation or atrial flutter. Many patients are admitted overnight by the NF residents or are transferred from the CICU after undergoing invasive procedures such as percutaneous intervention. Team Structure: 1 attending, 2 senior residents, 4 interns Cap: 10 patients per intern Admission Guidelines: Short – 1NF or CICU transfer prior to 1PM (none if clinic or on the weekend); Medium – 2 admissions prior to 4PM; Long – 3 admissions prior to 7PM; Precall – no admissions and off Fri-Mon CICU Team Structure: 1 attending, 1 Cardiology Fellow, 4 day Senior Residents, 1 night Senior Resident, 2 Interns Cap: No Cap – max 20 beds in the CICU Call Structure: Q4 28h call On call: admissions from 7am-7am. Daytime admitting help from interns and nighttime admitting help from trading off with the night resident. Post Call: round on your patients, finish you work, and go home. Helper: Cross cover, stay till after afternoon rounds Interns: Daytime admitting 1-2 patients with SR every other day. Follow these patients. Should not carry more than 4. 041 Data Interpretation Fundamentals ECGs – always check patient name, date, gain Rate - Slow <60; Fast >100 --- pathologic or physiologic? Rhythm - regular or irregular Axis – Look at I, II - Normal: -30° to +100° o I, II all + - Left: -30° to -90° o I +; II neg vs isoelect - Right: +100° to +180° o I, II Source: Harrisons 18th Edition Waves: P: atrial depolarization Right Atrial Enlargement – high amplitude II, positive net deflection V1 Left Atrial Enlargement – wide P-wave II; negative net deflection V1 Normal – equal biphasic V1; 1x1 box in II *** if negative deflection in V1, HIGH LIKELIHOOD for lead misplacement QRS: ventricular depolarization – width indicates ventricular synchrony RBBB o QRS >120 o rSR’ (bunny ears) in V1, V2 LBBB o o o o QRS >120 Notched, slurred R wave in I, aVL, V5, V6 Deep S waves in V1, V2 Prolonged time to peak R wave in V5, V6 Also to Diagnose LVH – Sokolow-Lyon System o SV1 + RV5 >35 little boxes o RaVL > 11 little boxes Source: Harrisons 18th Edition T: ventricular depolarization - May be inverted in areas of ischemia suggestive of subendocardial ischemia or NSTEMI; CANNOT reliably localize an artery based on T wave abnormalities alone - Wellen’s T Waves – deeply inverted biphasic T waves in V2, V3 – highly specific for critical stenosis in the LAD. Patients may be asymptomatic at time of ECG but are at high risk for anterior MI in the ensuing days to weeks U: not always present; can appear in hypokalemia 042 Intervals: PR – normal 120-200 ms QRS - <100-120ms QTc < 440ms ST – Elevation in right clinical context suggests acute complete occlusion and necessitates emergent revascularization Area of Infarction Inferior Anterior Lateral True Posterior Septal Anterolateral Inferolateral ECG Leads Related Artery II, III, aVF V2-V4 I, aVL, V5, V6 Tall R wave in V1 V1-V3 I, aVL, V2-V6 II, III, aVF, I, aVL, V5, V6 RCA or posterolateral branch LCx LAD or 1st Diag LCx Posterolateral branch LCx or PDA of RCA LAD or 1st Diag Prox Diag Prox Cx; large RCA if R Dominant ** ST ELEVATION DOES NOT NECESSARILY MEAN ISCHEMIA DDx includes – normal variant, LVH, LBBB, acute pericarditis, hyperkalemia, Brugada Syndrome, PE, immediately after DCCV, Prinzmetal Angina *** 90% of health young men have a concave ST elevation of 1-3mm in V2 TP – high variability; use this segment to determine isoelectric line Coronary Angiography (sometimes called left heart cath): Useful tool to diagnose extent of coronary disease and deliver percutaneous interventions Usually Femoral vs Radial Access Indications: - Known or suspected CAD – persistent angina despite medical treatment, high risk criteria on noninvasive testing, patients resuscitated after sudden cardiac death, patients who have had >30 sec of monomorphic VT or <30 sec of polymorphic VT - Nonspecific Chest Pain w/ high risk features on noninvasive testing - Unstable Angina/NSTEMI – refractory angina, hemodynamic or electrical instability, or high risk for MACE - STEMI – primary rescue PCI, cardiogenic shock who are candidates for PCI - Suspected Abrupt closure or in-stent thrombosis after PCI Relative Contraindications - Coagulopathy - Uncontrolled HTN - Pregnancy - Renal Failure 043 - ** contrast allergy is NOT a contraindication – patient can be prepped with sterioids and antihistamine therapy Risk of Major Complications is 1-2% - includes death, MI, stroke, bleeding, contrast reaction – operator dependent and lower risk at tertiary care centers Views: Identifying View RAO vs LAO (R Anterior Oblique vs L Anterior Oblique) - If spine and catheter are to the right of the image, LAO Cranial Vs Caudal - If diaphragm can be seen, likely cranial view Anteroposterior (AP) - Visualize Left main ostium; distal RCA bifurcation RAO Caudal – best view for prox/mid LCx and Distal LAD LAO Caudal – Left Main, prox LAD and prox LCx RAO Cranial – mid/distal LAD, distal LCx; mid RCA and PDA LAO Cranial – mid/distal LAD, diags, prox LCx; ostial/prox RCA Interpretations: - Presence of acute thrombus vs ulceration - TIMI flow pre- and post-intervention Echocardiography: 3 BASIC VIEWS ALL INTERNISTS SHOULD KNOW Parasternal Long Axis (PLAX) – left sternum between 3rd and 5th intercostal spaces Parasternal Short Axis (PSAX) - Probe location same as PLAX, but rotated 90 degrees - Shows cross sections of LV walls at level of AV, MV, and mid ventricle 044 Source: Harrison’s 18th Edition and public access images Apical 4 Chamber - Probe at LV apex max impulse For More Info, please check out: https://web.stanford.edu/group/ccm_echocardio/cgibin/mediawiki/index.php/Parasternal_long_axis_view (Also a source for above images) Right Heart Cath Interpretation *** Right heart catheterization means measuring pressures on the right side of the heart with the intention of understanding the volume status of the patient. It is NOT the evaluation of the right coronary artery*** In cardiogenic shock, lab may leave Swan in for CICU to use for management. Common Parameters w/ Normal Values Right Atrial Pressure (RAP) – same as your JVP – 1-5mm Hg Pulm Artery Pressure (PAP) – ~25/10 mm Hg Pulm Capillary Wedge Pressure (PCWP) – represents left atrial pressure – 4-12 mm Hg Cardiac Output (CO) – calculated from Fick Equation Cardiac Index (CI) – CO/Body Surface Area In the CICU, cardiogenic shock patients will frequently have CI of <2.0; the goal will be to guide therapy to a CI >2.4 045 Systemic Vascular Resistance (SVR) - 700-1600 woods units (MAP – CVP) / CO Pulmonary Vascular Resistance (PVR) – 20-120 woods units (PAP – PCWP) / CO Chest Pain Mr. Wellen is a 54 y/o gentleman presents with 8 hours of midsternal chest pain. His ECG was negative. What’s the Differential??? Be broad and think by organ systems. Cardiac – Angina, MI, Pericarditis Vascular – Aortic Dissection, PE, Pulm HTN Pulmonary – Pleuritis/PNA, Pneumothorax, Bronchitis GI – GERD, Peptic Ulcer, Gallbladder, Cholecystitis, Pancreatitis MSK – Costochondritis, Cervical Disc Disease, Trauma, Muscle Strain ID – Herpes Zoster Psych – Panic disorder, anxiety What to do? 1st ---- is the patient hemodynamically stable? NO Ask for HELP, assess for STEMI, Massive PE, Aortic Dissection, Cardiac Tamponade, Tension Pneumothorax, PE. YES History + Phys Exam (HIGH YIELD) - Reproducibility w/ palpation, exertion? - Prolonged pain at rest or minimal exercise in the last 12 hours? - Assc w/ nausea, diaphoresis? Radiating to left arm or neck? - Similar to any previous MIs? - Improves with rest? Improves with nitro? ECG + CXR (HIGH YIELD) --- r/o PNTX, STEMI; check for pericarditis If + ECG changes, check cardiac biomarkers (Troponins, CKMB) o ST changes >1 little box or TWI >3 little boxes in 3 or more limb leads or 4 or more precordial leads? Widened mediastinum on CXR, consider aortic dissection – CT Angio vs MRI vs TEE Pulm Infiltrate – consider PNA, lung abscess, empyema High Suspicion for Coronary Ischemia Patient Story + ECG changes + Biomarkers 1. Admit to telemetry 2. Bed rest 3. Make NPO for a stress test or cardiac catheterization the following day 4. Oxygen 5. EKG on admission and in the morning 6. Labs – troponin q8, CBC, CMP, coags, lipid profile, HgA1c 7. Aspirin 325mg x1 and then 81mg by mouth daily 8. Sublingual Nitroglycerin vs nitro paste vs nitroglycerin drip 046 9. Metoprolol Tartrate (as long as patient is not in decompensated heart failure). Start q6h and titrate to HR 60. 10. Atorvastatin 80mg PO daily – check LFTs Acute Coronary Syndromes Unstable Angina / NSTEMI - Continue Aspirin, Beta Blockade, Statin, Nitrates as above - Initiate Anticoagulation with Heparin gtt with a bolus - Antiplatelet – usually clopidogrel 600mg x1 dose followed by 75mg by mouth every day thereafter (some cardiologists prefer ticagrelor) - Refer for cardiac catheterization for further evaluation and possible intervention STEMI - In appropriate clinical setting and significant ST elevations in contiguous leads ACTIVATE CATH LAB; usually done by outside hospital ED or our ED Post STEMI Complications - LV Free Wall Rupture – chest pain, SOB, hypotension, cardiogenic shock - VSD – usually assc w/ new harsh thrill on examination (3-7 days post) - Papillary muscle rupture – abrupt SOB, pulm edema, hypotension - Cardiogenic Shock - LV Aneurysm (several weeks post) - Early Pericarditis - Delayed Pericarditis (Dressler’s Syndrome) - Arrhythmias RV Infarction: Clinical triad of --- hypotension, clear lung fields, elevated JVD Perform a Right Sided ECG Treatment – Fluids, fluids, fluids --- need to maintain RV preload Reduce RV afterload Provide inotropic support if needed (dobutamine) Revascularization w/ PCI Heart Failure Mrs. Ganz is a 52 year old lady who presents with a 3 week history of gradual increased SOB, 15 pound weight gain, abdominal distension and lower extremity swelling. What to do? History - Ask about orthopnea, PND, cough, chest pain, dizziness, lightheadness, palpitations - How much weight gain? Is there a previously known dry weight? - Compliance to home medications – especially diuretics? Dietary habits and salt intake? 047 - - Try to pin down exercise capacity specifically in terms of activities and judge NYHA classification o Class I – symptoms with fairly significant activity, well compensated o Class II – symptoms at moderate activity o Class III – symptoms at minimal activity (<1 block flat, <1 flight stairs) o Class IV – symptoms at rest Ask about family history, personal hx of coronary disease, hx of illicit drug use (cocaine) Phys Exam: - GOTTA CHECK THE NECK VEINS! - Heart Sounds - is there an S3? Remember to listen for KEN-TU-CKY - Monitor leg swelling and check weights daily as a supplemental measure of body volume - Pulm: differentiate RV vs LV and RV failure. Heart Failure can largely be categorized as such: - Systolic vs diastolic (EF <35%) - Ischemic vs Nonischemic o Ischemic Etiology – treatment should include strategies that target revascularization (CABG/PCI) vs medical therapy w/ statins, anti-platelet agents o Non-ischemic –hyper/hypothyroidism, autoimmune etiology, HIV Infiltrative Cardiomyopathies – sarcoidosis, amyloid, hemochromatosis HF Meds - Beta Blockers – only 3 beta blockers have shown mortality benefit in patients with HF and reduced EF o Metoprolol Succinate (Toprol XL – long acting); Metoprolol Tartrate is short acting – q6 to q12; daily dose to not exceed 400mg o Carvedilol (concomitant α1 antagonism w/ antihypertensive effect) o Bisoprolol - ACE-I / ARB o Lisinopril most commonly used o Can use captopril q8 dosing for shorter length titration. Conversion is 1mg lisinopril for every 5mg of daily captopril. For example, patient on 12.5mg captopril q8h converts to about 7.5mg lisinopril daily. - Nitrates + Hydralazine o Consider in patients w/ in whom ACE/ARB are contraindicated, i.e. acute renal failure, angioedema - Loop Diuretics (Conversion Chart Below) 048 Drug Initial Oral Dose (PO) Bioavail Furosemide 20mg 10100% Bumetanide 0.5mg 80100% Torsemide 20mg 80100% Ethacrynic 25mg 80Acid 100% - - PO Equivalents 80mg IV Equivalents 40mg Onset (hrs) 0.5 Peak (hrs) 1 Duration (hrs) 6 20mg 20mg 0.5 1 6-8 1mg 50mg 1mg 50mg 0.5 0.5 1 1 4-6 6-8 Spironolactone – aldosterone antagonist o Monitor potassium levels especially if patient is on supplemental K o Improves mortality in patients w/ reduced EF (NYHA III/IV) Digoxin – negative dromotrope and positive inotrope o Need to watch for digoxin toxicity o Improved symptoms, no mortality benefit Ms. G starts developing respiratory distress and pulse ox shows him satting 84% on RA. What to do? Ask for help! Check vital signs, assess for flash pulm edema? - Provide supplemental O2 – talk with MICU resident, senior resident. At UH consider code white if you think they need MICU tx. - STAT IV Lasix – usually start with 40mg IV x1 but can adjust dose based on patient’s home meds - obtain an ABG, ECG, CXR - if hypertensive with suspicion for flash edema, start IV Nitroglycerin drip - Full set of labs - Consider transfer to CICU for further monitoring, diuresis, and potential PA catheter guided therapies with inotropes and vasodilators Arrhythmias Mr. Brugada and his brother come see you in the office. His brother states he witnessed the patient pass out at home. This has happened 3 times in the last 6 months and last time Mr. B had complained of palpitations just before passing out. Symptoms resolved within a minute. The patient appears comfortable and denies any current chest pain or trouble breathing. Vital signs in the office reveal a BP of 125/83 and a pulse of 146. What to do?? Get an ECG!!!!! Ask Yourself 3 Questions – 1) Fast or Slow? 2) Regular or Irregular? 3) Narrow or Wide QRS? These 3 questions will narrow your differential diagnosis quickly and efficiently! 049 Narrow Complex, Fast - Atrial Fibrillation – irregular, no p-waves - Atrial Tachycardia – emperor of the SVTs – any p-wave morphology, can be regular or irregular - Multifocal Atrial Tachycardia – various p-wave morphologies usually in patients with concomitant pulmonary disease - Atrial Flutter – “sawtooth” – usually regular, reentrant - AVNRT - Regular, usually no P waves (atrial depol simultaneous with vent depol) - AVRT – Regular, because circuit is longer than AVNRT may see P waves after QRS Wide Complex, Fast - Ventricular Tachycardia – monomorphic or polymorphic; shock if hemodynamically unstable, otherwise can treat medically with amiodarone, lidocaine, etc. - Torsades De Pointes – a subset of polymorphic VT; can be assc w/ electrolyte abnormalities --- low Mg or from an “R on T” phenomenon in patients w/ prolonged QT o Check the drugs; Consider congenital electrical disturbances - VFib o Complete degeneration of the ventricular electrical conduction system o Irregular, no organized rhythms - SVT w/ aberrancy o Any of the narrow complex rhythms now traveling via an accessory pathway leading to early ventricular preexcitation and a wide complex on ECG Narrow Complex, Slow - 2nd degree, 3rd degree heart block o 2nd degree – Mobitz I vs Mobitz II o 3rd degree – complete discordance between atrial and ventricular depolarization - Sinus bradycardia – a sick sinus node but at a rate that is still faster than that of the intrinsic AV node pacemaker cells - Ventricular escape rhythm – HR usually 20-40 - Junctional Rhythm – HR usually ~40; can be accelerated junctional 40-80 Diagnosis and Treatment: Unstable Patients For all patients, ALWAYS determine if they are hemodynamically stable. If NOT, this is #1 priority. For fast heart rates, place pads and prepare for cardioversion. For slow heart rates, place pads and prepare for potential cutaneous pacing and may need to activate cath lab for placement of a temporary pacemaker. Stable Patients Fast Narrow Complex 050 - - Obtain an ECG; may need to use adenosine push while monitoring patient on a rhythm strip – this will attempt to slow the rhythm and allow you to identify it Afib – metoprolol IV vs PO, diltiazem, amiodarone, digoxin (BP may limit BB/CCB) Aflutter – tremendously difficult to control – best treatment is cardioversion o For both Afib/Aflutter, the patient must be anticoagulated for at least 4 weeks or have a TEE documented absence of intra-atrial clot Atrial Tachycardia – beta blockade vs centrally-acting calcium channel blockers AVNRT/AVRT – any AV nodal blocking agent should successfully terminate the reentrant circuit (adenosine usually more effective, have continuous EKG so EP can evaluate later) Fast Wide Complex - VT – amiodarone 150mg IV bolus followed by amiodarone drip o Can Also use lidocaine and esmolol drips if patient continuing to have breakthrough VT o If patient develops VT storm despite medical therapy, can activate cath lab for placement of Intraaortic Balloon Pump for mechanical assistance - Torsades – o Check and Replete Electrolytes, Give Mag 2gm over 1 min, can repeat q515minutes. May require DCCV (particularly if degenerates to V fib) o Treatment should also focus on narrowing QT – can use isoproterenol drip vs ensuring that patients AV nodal blockers are stopped o *** at this time, must be sure that this is NOT polymorphic VT from an ischemic etiology!! Especially if starting isoproterenol which will increase O2 demand. Slow Rhythms - Ensure that no AV nodal blocking agents are being administered - If bradycardia or heart block persists, patient will need a pacemaker placed for definitive therapy BONUS POINTS! Brugada Syndrome – a sodium channelopathy first described in 1992 by the Brugada brothers resulting in a significant cause of death in young males particularly in Southeast Asia. Appears to have autosominal dominant inheritance. ST segment elevations >2mm in V1-V3 followed by a neg T wave is called the Brugada Sign. Diagnosis is made when this finding is assc w/ documented VFib, polymorphic VT, family hx of sudden cardiac death <45 yrs, inducibility of VT during an EP study, syncope, or nocturnal agonal respiration. Implantable Cardiac Devices Permanent Pacemaker (PPM) --- FOR SLOW RHYTHMS - Indications: symptomatic bradycardia, symptomatic chronotropic incompetence, Mobitz 2 heart block; 3rd degree heart block - Any episodes of asystole >3 seconds; any escape rhythm <40 bpm - Patients may have episodes of bradycardia after an MI 051 o Bradycardia after posterior MI usually resolves spontaneously; usually persists after anterior MI as this is a marker of a large territory exposed to ischemia - Types of PPMs o Single Chamber – lead in 1 chamber (usually RV). VVI – ventricle sensed/paced; can be in RA A-sensed, A-paced o Dual Chamber – 1 lead in RA, 2nd lead in RV – A-sensed, V-paced; allows for A-V synchronization --- DDDR (dual chambers pace, dual chambers sensed, dual response) o Biventricular PM – 3 Leads! – one lead in RA, one in RV, and one in coronary sinus that paces LV Implantable Cardioverter-Defibrillator (ICD) – FOR FAST RHYTHMS - **all ICDs have pacemakers as well - Indications – primary, secondary o Primary Heart failure w/ EF <35% in Non-ischemic cardiomyopathy Patients w/ ischemic cardiomyopathy who are at least 40 days postMI and have persistent reduced EF <35% on optimal medical tx Patient’s w/ prolonged QT and family hx of sudden cardiac death – e.g., Brugada syndrome Cardiac Resynchronization Therapy (CRT) for patients with EF <35% and those with wide complex on ECG o Secondary – survivors of cardiac arrest from Vfib or sustained VT patients w/ syncopal events who have inducible VT during EP studies Common Device Issues 1. Failure to Sense – intrinsic rhythm is not detected by the PM; as a result, pacing is inappropriate – usually from lead dislodgement/fracture or programming errors 2. Failure to Pace – occurs with oversensing; inappropriate signals are sensed resulting in inappoproate pauses 3. Failure to Capture – no evidence of depolarization despite a pacing spike being delivered (no QRS after pacing spike). Sensing is intact. If occurs shortly after initial implant, likely from lead dislodgement or perforation. If occurs weeks/months later, then due to lead maturation issues with possible structural injury to the lead insulation or conductor. Mrs. Naxos is 67 year old lady who underwent elective placement of a dual chamber PPM yesterday by the EP service. She is being monitored in the CICU and the EP fellow requests that you manage care going forth. You visit Mrs. N in the morning – the pocket site looks good and her vitals are stable. How do you assess the new device? What to do? 1. Need a CXR after the procedure and 2 view CXR the morning after to ensure no progressing pneumothorax and proper placement of leads. Also need to assess for any enlargement in cardiac silhouette that could suggest hemopericardium. 2. Always obtain an ECG after device implantation and the morning to ensure that the device is sensing and pacing appropriately. 052 3. If a temporary pacing wire is in place, it’s important to check the capture threshold and the intrinsic rhythm of the patient. The capture threshold can be adjusted with a device at the bedside – the cardiology fellow will show you how to do this! Crucial Cardiovascular Physical Exam Techniques: JVP - Relax patient, remove pillows, ensure a well-lit room - Look for a bifid pulsation (first “a” wave, then “v” wave) and see if it moves as you alter the head of the bed - Press on the RUQ and assess for change in pulsation – hepatojugular reflux - Identify the highest point of pulsation and measure vertical distance from the angle of Louis o Angle of Louis – sternal angle – junction of manubrium and sternum -- 5cm H2O from the center of the left atrium ** KEY Venous Pulsation Findings** Cannon A wave – large initial pulsation that occurs when RA contracts against closed tricuspid valve. Occurs intermittently during conditions with AV dissociation – VT, complete heart block Kussmaul Sign – neck veins rise during inspiration – a sign of pericardial tamponade Pulsus Paradoxus – a drop in SBP >10mm Hg with inspiration - Check BP w/ manual cuff – inflate at least 20mm Hg above the pressure at which radial pulse disappears - Deflate slowly until you hear any sounds (intermittently regardless if these correspond with heart rate) and record highest SBP - Continue to deflate slowly until you hear sounds with every heart beat – difference between these two pressures is the “pulsus” - During inspiration, intrathoracic pressure decreases and right heart filling increases. In tamponade, the increased RV blood exerts force on the interventricular septum causing a left sided bulge and reduced systemic stroke volume and a resulting significant (>10mm Hg) drop in SBP. Heart Sounds and Murmurs S3 – after S2, low pitch, assc w/ volume overload in CHF – left lat decub at cardiac apex S4 – before S1, atrial gallop – blood being forced into a stiff, hypertrophic LV Mitral Regurg – holosytolic murmur at apex; similar to TR (at LLSB) Aortic Stenosis – systolic crescendo/decrescendo w/ radiation to carotids at RUSB Aortic Regurg – diastolic decrescendo murmur Mitral Stenosis – mid diastolic soft rumbling murmur w/ OPENING SNAP Rub – scratching, creaking, high pitch usually at beginning and end of diastole assc w/ pericarditis 053 UH MICU Tips and Time Savers 1. Rounds generally start at 8 am with CXR and imaging rounds at the back. 2. Unit coverage: You can leave the unit, just let team know how to reach you and how long you will be gone. 3. Resident/Intern Schedule: Hanging up next to a computer terminal in back of unit. Please write you days off so the NP’s can help figure out who may need help with coverage on your days off. 4. Privacy/Dignity: Keep curtain shut when examining patients. 5. Isolation: Need to wash hands prior to entering patients room and when coming out. Pay attention to isolation signs outside of rooms! 6. Kathy and Rachel NP’s are here four -10hour days – when not here their patients have to be covered by the residents. Their role is to take patients with known diagnosis and predictable course. They perform H&P’s, physical exams, diagnosis, write notes, call consultants and manage day/day issues. If needed they can help place dobhoffs, a-lines & femoral lines. They are discharge planning experts. 7. Respiratory therapy: at least one assigned to the unit at all times. Only Respiratory therapy, the Attending or Fellow may make ventilatory changes. 8. Charge Nurse: knows about bed availability, status on incoming pts…. 9. Social Work – is available to assist with any and all social work issues. Call early, these discharges can get complicated. 10. Nutritional support should usually be started within 24 hrs of admission. Dietician is available for assistance with tubefeeds/TPN. 11. Pharm D: Andreea Popa 31503 is available to help with medication dosing and availability. 12. Keep side rails up at all times unless pt is alert and oriented and allowed to walk around. 13. Document DNAR discussions in the chart and place order. Make sure you include added limitations. Discuss advanced directive with all admissions. 14. The unit is a Family Centered Care Unit – frequently family members will attend rounds. We encourage frequent family meetings and updates to keep them abreast of changes. During an arrest, the family is asked if they want to stay in the room. A staff member will stay at their side to support them and answer questions. Visiting hrs are 24/7 for immediate family. Other visitors are invited between 11am and 7pm. Communication is KEY to appropriate goal setting. 15. We work as a team. The RNs are outstanding teammates. If a MICU RN asks you to assess a patient, assess the patient. If they are concerned about something, go with them to the bedside. A MICU RN expressing concern about a patient more than once in a day is a highly specific sign of a patient who is about to decompsensate without attention. 16. Workflow: Most days in the unit you will have 3 or fewer patients to cover as an intern. Beware, prerounding well on a MICU patient takes 30-60 minutes per patient. Have a discussion with the RN every morning. Look at all new imaging, labs, vitals. Know vent settings, drip rates. Be prepared for a detailed systems 054 based presentation on rounds. Notes should be detailed and fully updated, delete outdated information. Transfer notes should be updated daily if patient is to leave the unit. Unless you are the post-call resident, no intern or resident should leave the unit prior to 4PM on any day. Even if you are done with your work, there is always activity, procedures, learning to be done in the ICU. Moreover, the on call team is busy, and taking your sign out early is one more task for them. 17. W.O.W.s (workstation on wheels) need to be plugged in when not in use. The battery is only good for 2hrs and if it completely discharges, it will not charge up completely, making for a miserable day. 18. Days off: Precall day for senior residents Fri-Mon, Helper day for interns Fri-Mon 19. Patients in the unit are everyone’s responsibility. Whether you are covering for a day or just covering while your team gets lunch, we take responsibility for any active issue on any patient in the unit. Orders: 1. EMR: Please be sure to place order for Admission with Pulmonary Critical Care as the service. Complete the medication reconciliation on admission. 2. EMR: Medications: Please order medications that need to be given at a specific time ie: antibiotics, as “time specific” and not “stat”. If you just order it BID or even q 8 hrs it may not get given in a timely fashion. 3. Every patient needs some form of DVT prophylaxis (SCDS count)and if they are on a vent, GI prophylaxis (PPI?). 4. Radiology tests: Place as STAT orders, include specific suspicion so radiology can comment on this. 5. CXR’s-need to be ordered daily on all ET intubated patients. Once pt is considered chronic, stable, do not need to order daily CXR’s (if trach). 6. STAT orders: Verbally notify the nurse what they need to do (med or labs). 7. Daily Labs : Order floor to collect (all labs are floor to collect in unit). 8. Transfers out: Need to place EMR order to transfer out, notify nurse and the secretary to get a bed, and update orders (ie. Stop all ICU type orders). Page DACR 30512 (or call 67121)to let them know about the patient. Give verbal report to team accepting the patient. If not done by the time you leave, sign out that report still needs to be called. 9. Palliative Care Service: available to help with difficult patients/families/siutations. 10. Ethics Consult: available when pts unable to make own decisions, if they have no family, and for ethical dilemmas 11. Keep track of how long a line has been in, what the site is looking like and daily ask yourself if you still need it-if you don’t need it remove it. (Remember, new dialysis patients will need some form of access before removing any other access). 12. Trachs- fresh tracheostomy is performed bedside by ENT (for most patients). Sutures need to be in place for 5 days, then ENT can remove them. Therefore a pt needs to stay in the unit until the sutures get removed. Ventilator patients: Daily wake up assessments (turning off sedation/narcotics) 055 should be done on all patients once O2 requirements <55%, PEEP < 10, reason for intubation identified and treatments started. While awake, patients should be assessed for delirium using the CAM ICU score and weaning parameters obtained, if appropriate. If weaning trial done, know the NIF and RSBI for rounds. It is helpful to remind the bedside nurse/RT to do this assessment after 8am in the morning 056 INFECTION SOURCE / SETTING Community Acquired Pneumonia (ICU) Hospital Acquired, Ventilatorassociated and Healthcareassociated Pneumonia PCN allergy: Cefepime 2 gm q 8 hrs OR Meropenem 1gm q 8 hrs, based on allergy severity If recent positive culture for MDR GNR, or severe sepsis/septic shock: consider adding Tobramycin If HCAP and patient resides in community: add Levofloxacin or Azithromycin (Legionella coverage) To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage) Piperacillin/tazobactam 4.5 gm q 6 hrs *If Pseudomonas suspected: Piperacillin/tazobactam 4.5 gm q 6 hrs+ Levofloxacin 750 mg daily PCN allergy: substitute Piperacillin/tazobactam with Aztreonam 2 gm q 8 hrs If recent positive culture for Pseudomonas, or recent fluoroquinolone use, or if severe sepsis, septic shock: consider adding Tobramycin For severe CAP ADD: Vancomycin 15 mg/kg q 8-12 hours Ceftriaxone 1 gm daily + Azithromycin 500 mg daily OR Ceftriaxone 1 gm daily + Levofloxacin 750 mg IV daily EMPIRIC THERAPY UNIVERSITY HOSPITALS OF CLEVELAND CASE MEDICAL CENTER MICU INITIAL EMPIRICAL ADULT IV ANTIBIOTIC THERAPY LIKELY PATHOGENS S. pneumoniae, Legionella, H. influenzae, Mycoplasma, Chlamydia S. pneumoniae, Legionella, H. influenzae, MSSA P. aeruginosa, Anaerobes, Enterobacteriaceae, Acinetobacter sp., MRSA Piperacillin/tazobactam 4.5 gm q 6 hrs OR Community acquired: Ceftriaxone 1 gm daily; PCN allergy: Aztreonam 1 gm q 8 hrs Hospital acquired: Piperacillin/tazobactam 3.375 gm q 6 hrs PCN allergy: Cefepime 2 gm q12 hrs OR Aztreonam 1 gm q 8 hrs based on allergy severity If severe sepsis/septic shock, or current positive blood culture for GNR: consider adding Medical Intensive Care Unit SEPSIS Resource 2015 Keith Armitage MD Andreea Popa, Pharm.D. BCPS Constantine Tsigrelis MD Edited by: Mariana Petrozzi M.D. Sepsis: Infection, documented or suspected and some of the following Hemodynamic variables Inflamm. variables Arterial hypoxemia (PaO2/FiO2 < 300) Acute oliguria (urine output <0.5 mL/kg/hr for at least 2 hours despite adequate fluid resuscitation) Creatinine increase >0.5 mg/dL Coagulation abnormalities (INR>1.5 or aPTT>60s) Ileus (absent bowel sounds) Thrombocytopenia (platelet count <100,000 mcL-1) Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL) Arterial hypotension (SBP<90 mmHg , MAP <70 mmHg , or an SBP decrease >40 mm Hg in adults or less than 2 SD below normal for age) Leukocytosis (WBC count > 12,000 mcL-1) Leukopenia (WBC count <4000 mcL-1) Normal WBC count with > 10% immature forms Plasma C-reactive protein > 2 SD above normal Plasma procalcitonin > 2 SD above normal General variables Organ dysfxn. variables Hyperlactetemia (>1 mmol/L) Decreased capillary refill or mottling Fever (>38.3 ºC) Hypothermia (core temperature <36 ºC) HR > 90/min-1 or more than 2SD above the normal for age Tachypnea Altered mental status Significant edema or positive fluid balance (>20 mL/kg/ 24 hrs) Hyperglycemia (BG >140 mg/dL) in the absence of diabetes Tissue perfusion variables Severe Sepsis: sepsis induced tissue hypoperfusion or organ dysfunction Sepsis induced hypotension Lactate above upper limits laboratory normal UO <0.5mL/kg/hr for more than 2 hours despite adequate fluid resuscitation ALI with PaO2/FiO2 < 250 in the absence of pneumonia as infection source ALI with PaO2/FiO2 <200 in the presence of pneumonia as infection source Creatinine >2 mg/dL Platelet count < 100,000 mcL-1 Coagulopaty (INR >1.5) Septic Shock: sepsis induced hypotension persisting despite adequate fluid 057 Enterobacteriaceae, , PCN allergy: Cefepime 2 gm q 8 hrs OR Meropenem 1gm q 8 hrs, based on allergy severity P. aeruginosa, Neutropenic Fever If recent positive culture for MDR GNR, or if severe sepsis/septic shock, or if current positive Streptococcus sp., blood culture for GNR: consider adding Tobramycin MRSA, MRSE To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage) Urinary Tract Infections Enterobacteriaceae, , Enterococcus E. coli, K. pneumoniae, P. aeruginosa, Enterococcus Piperacillin/tazobactam 3.375 gm q 6 hrs OR PCN allergy: Cefepime 2 gm q 12hrs + Metronidazole 500 mg q 8 hrs OR Meropenem 1 gm q 8 hrs based on allergy severity Vancomycin 125 mg PO q 6 hrs (if ileus, toxic megacolon add IV metronidazole +/- rectal vancomycin Vancomycin 15 mg/kg q 12 hrs +( Ceftazidime 2 gm q 8 OR Cefepime 2 gm q 8 hrs OR Meropenem 2 gm q 8 hrs) Hospital acquired, Post procedure: Ceftriaxone 2 g q 12 hrs + Vancomycin 15 mg/kg q 8-12 hrs; (If > 50 yo and suspect Listeria add Ampicillin 2 gm q 4 hrs) Acyclovir 10 mg/kg (use IBW if obese) q 8 hrs (if suspected viral encephalitis) Community acquired: Give with or just before the 1st dose of antibiotics for suspected/known pneumococcal meningitis: Dexamethasone 0.15mg/kg IV q6 hrs x 2-4 days Piperacillin/tazobactam 3.375 gm q 6 hrs OR PCN allergy: Cefepime 2 gm q 12 hrs + Metronidazole 500 mg q 6 hrs OR Meropenem 1 gm q 8 hrs based on allergy severity ADD Clindamycin 600 mg q 8 hrs for necrotizing fasciitis To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage) Start with: Vancomycin 15 mg/kg q 8-12 hours until MRSA ruled out and then narrow coverage using: Nafcillin 2 gm q 4 hrs OR Cefazollin 1 gm q 8 hrs PCN allergy: substitute Piperacillin/tazobactam with Cefepime 2 gm q12 hrs OR Aztreonam 1 gm q 8 hrs based on allergy severity Vancomycin 15 mg/kg q 8-12 + Piperacillin/tazobactam 3.375 gm q 6 hrs Gentamicin Intra-Abdominal Infections Enterobacteriaceae, , P. aeruginosa, Enterococcus, Anaerobes Streptococcus sp., Staphylococcus sp. (MRSA) Vascular Catheter- Staphylococcus sp. (MRSA), Related Enterococcus Infections Cellulitis/Limb Infections (Normal Hosts) Community acquired: S. pneumoniae, N. Meningitidis, Listeria, H. influenzae Hospital acquired, Post procedure: S.aureus, P.aeruginosa, Enterobacteriaceae, Enterobacteriaceae, , P. aeruginosa, Enterococcus, Anaerobes Meningitis/ Encephalitis Clostridium difficile Diabetic/PVD limb infections and cellulitis C. difficile Diarrhea *Clinical Risk Factors for infection with Pseudomonas in CAP: Structural lung disease (brochiectasis), or repeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic use, and prior antibiotic therapy. Presence of risk factors for HCAP :hospitalization for 2 days or more in the preceding 90 days; residence in a nursing home or an extended care facility; home infusion therapy, chronic dialysis, home wound care, family member with MDRs Tobramycin and gentamicin dosing should be individualized based on diagnosis and renal function. Round Vancomycin dose to the nearest 250 mg. Piperacillin/ tazobactam, Acyclovir, Aztreonam, Ciprofloxacin, Cefepime, Metronidazole, Ceftazidime, Meropenem and Vancomycin will need dosage adjustment for renal disfunction. - Change in mental status - ¯Urine Output (UO) -↑ Lactate > 4 mmol/L FLUID Therapy Crystalloids or Colloids titrated to clinical endpoints Maintain Hb 7-9 g/dL BP at goal? (one attempt, if fails move to next step) NO Consider invasive hemodynamic monitoring • Central Venous Pressure (CVP) Adequate filling pressure? YES VASOPRESSOR Therapy Adequate CO YES BP at goal? NO Dobutamine (preffered) Inotropic Therapy NO • Arterial Cannula; • Establish resuscitation goals -Clinical Endpoints: BP, HR, UO, skin perfusion, mental status -Indices of perfusion: lactate, mixed or central venous oxygen saturation ICU Admission - SBP<90mmHg - MAP<65 mmHg - ¯ SBP > 40 mmHg SEPSIS with Hypotension or signs of Hypoperfusion Hemodynamic Support of Adult Patient with Severe Sepsis and Septic Shock YES YES Adequate perfusion? YES NO Norepinephrine as the first choice Epinephrine added when an additional agent is needed Titrate to MAP ≥ 65 mmHg Consider replacement dose STEROIDS in vasopressor refractory septic shock patients NO Refractory septic shock -Vassopressin 0.03 units/min may be added to NE with anticipation of an effect equal to NE alone Establish re-evaluation interval (q15-30 min) Aggressive titration of fluids and vasopressorsto maintain established goals of resuscitation based on clinical endpoints and indices of perfusion Notice: Readers are encouraged to confirm the information contained herein with other resources. Surviving Sepsis Campaign Bundles TO BE COMPLETED WITHIN 3 HOURS 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L TO BE COMPLETED WITHIN 6 HOURS Adjunctive Therapies 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP ≥ 65 mmHg 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L reassess volume status and tissue perfusion and document findings as EITHER: - Focused exam (after initial fluid resuscitation) by licensed independent practitioner ( vital signs, cardiopulmonary, capillary refill, pulse and skin findings) - OR TWO OF THE FOLLOWING: Measure CVP, Measure ScvO2, bedside cardiovascular ultrasound, dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge Blood Products 1. Once tissue perfusion resolved and in the absence of : myocardial ischemia, severe hypoxemia, acute hemorrhage and ischemic heart disease, red blood cell transfusion should occur only when Hg < 7.0 g/dL to taget Hg 7.0-9.0 g/dL 2. Administer platelets when < 10,000/ mm3 in the absence of apparent bleeding, when < 20,000/ mm3 if significant risk of bleeding 1. Maintain blood glucose 140-180 mg/dL with insulin using unit algorithm 3. Higher counts ≥ 50,000/mm3 are advised for active bleeding , surgery or invasive procedures Glucose Control Intermittent hemodialysis and CVVH are considered equivalent; CVVH offers easier management in HD unstable patients Mechanical Ventilation Renal Replacement Do not use for purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion induced lactic acidemia with pH>7.15 1. Target a tidal volume of 6ml/kg IBW in patients with sepsis induced ARDS 2. Maintain inspiratory plateau pressure to <30 cmH 2O 3. Use PEEP to avoid alveolar collapse Bicarbonate Therapy Vasopressors and Inotropes Fluids Initial resuscitation 1. Norepinephrine (NE) is the first choice vasopressor 2. Epinephrine (added to and potentially substituted for NE) when an additional agent is needed 3. Low dose vasopressin can be added to NE with intent of either raising MAP or decreasing NE dose 4. Low dose vasopressin is not recommended as single initial vasopressor; higher doses only recommended as salvage 5. Dopamine as an alternative to NE only in highly selective patients ( low risk of tachyarrhythmias and absolute or relative bradycardia) 6. Phenylephrine is NOT recommended in the treatment of septic shock except: when NE is associated with serious arrhythmias or CO is known to be high and BP persistently low - salvage therapy 7. A trial of dobutamine up to 20 mcg/kg/min +/- vasopressor in the presence of myocardial dysfunction or ongoing signs of hypoperfusion 1. Crystalloids are the initial fluids of choice; albumin should be used only when patients require substantial amounts of crystalloids 2. Hydroxyethyl starches should not be used 3. Use fluid challenges of 30 mL/kg crystalloid 4. Fluid challenges as long as there is hemodynamic improvement based on dynamic ( change in pulse pressure, stroke volume variation) or static (arterial pressure, heart rate) variables. MAP ≥ 65 mm Hg, urine output ≥ 0.5 mL/kg/hr, CVP of 8-12 mm Hg (12-15 mm Hg in MV patients), Central venous or mixed venous oxygen saturation 70% or 65% , normalize lactate Guidelines for Management of Severe Sepsis and Septic Shock Source control and antibiotics 1. Administration of effective intravenous antimicrobials within the FIRST HOUR of r ecognition of septic shock and sever e sepsis without septic shock. 2. Initial empiric anti-infective therapy (see table) of one or more drugs that have activity against all likely pathogens and that penetrate in adequate concentrations into tissues presumed to be the source of infection 3. Reassess antimicrobial regimen daily for potential de-escalation, to optimize efficacy, prevent resistance, and avoid toxicity 4. Combination therapy for neutropenic patients with severe sepsis and for patients with difficult to treat multi drug resistant pathogens ( A cinetobacter and Pseudomonas spp.) 5. Empiric combination should not be administered for > 3-5 days: deescalate to most appropriate single therapy as soon as susceptibilities known 6. Duration of therapy : 7-10 days ; longer courses in patients with slow clinical response, undrainable foci, bacteremia with S.aureus Steroids (hydrocortisone 50 mg IV q 6 ) 1 0 0 0 2 ++ +++ + ++++ ++++ 1 0/+ +++ +++ 0 0/+ 0/+ 2 0 0 0 0 ++++ ++++ 0 DA1 ++++ 0 0 0 0 0 0 0 V1 ↑ ↓/↑ 0 MAP ↑ ↑ ↑ 0 CO ↓ 0/↓ ↓ 0 0 0 SVR ↑↑ 0/↑ ↑↑ ¯ HR VASOPRESSIN (units/min) 0.03 (mcg/kg/min) 2- 10 > 10 – 20 DOBUTAMINE ↓ ↓ ↓ 0 0 0 PCWP 1. Do not use IV hydrocortisone to treat adult septic shock if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability 2. If hyemodynamic stability not achievable use IV hydrocortisone alone at a total daily dose of 200 mg via intermittent dosing or continuous infusion 3. ACTH stimulation test is not recommended to identify septic shock patients who should receive treatment with IV hydrocortisone 4. Taper the IV hydrocortisone dose when vasopressors are no longer required 0 0/+ +++ 0 +++ ++ 0 0 0 0 0/↓/↑ HEMODYNAMIC EFFECTS ++ +++ +++ 0 0 0 0 0 RECEPTOR ACTIVITY ++++ 0 0 ++ +++ 0 AGENT ++++ 0 ++++ ++++ 0 (mcg/kg/min) EPINEPHRINE (mcg/kg/min) 0.01-0.05 >0.05 0 0 0 0 DOPAMINE NOREPINEPHRINE (mcg/kg/min) 0.05-0.5 + ++ 0 1-3 3-10 10-20 PHENYLEPHRINE (mcg/kg/min) 0.1-4 0 Dellinger RP et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013 MILRINONE (mcg/kg/min) 0.375 – 0.75 058 12 Andreea Popa, PharmD, BCPS Critical Care Clinical Pharmacist Liz Hohner, PharmD Candidate P A I N , A G I TAT I O N , D E L I R I U M A N D P A R A LY S I S MEDICAL INTENSIVE CARE UNIT Barr J, Fraser GL, Puntillo K, Ely EW, et al. Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306. • Preferred assessment tools for pain in ICU patients Pain Key Guideline Recommendations Assess • Non-neuropathic pain: IV opioids +/- non-opioid analgesia • Neuropathic pain: gabapentin or carbamazepine + IV opioids − Self-report of pain preferred − Behavioral pain scale (BPS 3-12) − Vital signs alone should not be used Treat • Pre-procedural analgesia +/- non-pharmacologic interventions • Treat pain first, then sedate Agitation Prevent • • • • Target lightest level of sedation possible Implement daily sedation interruption Use analgesia-first sedation Non-BZD for sedation (propofol or dexmedeomidine) are preferred, unless EtOH or BZD withdrawal is suspected • Management vious dose − Undersedated (RASS > 0): assess / treat pain then sedatives PRN − Oversedated: hold sedatives until at target then restart at 50% of pre- when patients at goal sedation level (unless contraindicated) • Consider daily spontaneous breathing trials, early mobility and exercise apy is indicated for increased ICP • EEG monitoring if patient is at risk for seizures or burst suppression ther- *auditory evoked potentials, bispectral index, narcotrend index, patient state index or state entropy Prevent Treat • RASS (-5 to +4) is the preferred assessment tool for depth and quality of sedation • If using neuromuscular blocking agents, objective measures of brain function* should be used as an adjunct to subjective sedation assessAssess ments. • EEG monitoring to detect non-convulsive seizure activity and to titrate electrosuppressive medications for burst suppression in patients who known or suspected seizures 059 2 Assess Treat Prevent Delirium • Preferred assessment tools for delirium in ICU patients − CAM-ICU (+ or - ) hearing aids • Treat pain as needed • Reorient patients, familiarize surroundings, use patient’s eyeglasses or for sedation, unless delirium is related to EtOH / BZD withdrawal • Pharmacologic treatment − Avoid BZD unless suspect EtOH / BZD withdrawal − Avoid rivastigmine − Atypical antipsychotics might reduce the duration of delirium − Avoid antipsychotics if at risk for QTc prolongation • If sedation is required in delirious ICU patients, use dexmedetomidine • Identify delirium risk factors: pre-existing dementia, HTN, history of EtOH abuse, high severity of illness, coma, BZD use Avoid BZD use in those at risk for delirium Do not use antipsychotics prophylactically to prevent delirium Mobilize and exercise patients early Promote sleep: control light, noise, cluster patient care activities, decrease nocturnal stimuli • • • • • Restart baseline psychiatric meds if indicated Sedation and Delirium Assessment Tools -4 -3 -2 -1 0 +1 +2 +3 +4 Unarousable Deep sedation Drowsy Alert and calm Restless Agitated Very agitated Combative No response to voice, but movement or eye opening to stimulation Moderate sedation Movement or eye opening to voice (but no contact) Light sedation No response to voice or physical stimulation Briefly awakens to voice (eye opening and contact <10 sec) Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) Anxious, apprehensive but movements are not aggressive or vigorous Frequent non-purposeful movement, fights ventilator Pulls or removes tube(s) or catheters(s); aggressive Combative, violent, immediate danger to self Richmond Agitation-Sedation Scale (RASS) -5 Sessler, et al. Am J Repir Crit Care Med 2002, 166; 1338-1334. Ely, et al. JAMA 2003; 286: 2983-2991 Neuromuscular Blocking Agents 11 060 10 Delirium in the ICU Prevention • Optimize ICU environment • Early mobilization • Do not disturb normal sleep • Avoid benzodiazepines • Limit dopaminergics, GABAagonists and anticholingergics • Analgesia first “sedation” • Use of alpha-2 agonists (dexmedtomidine) • Prophylactic pharmacologic prevention is NOT recommended Delirium is associated with increased mortality, prolonged ICU and hospital length of stay and development of post-ICU cognitive impairment in adult ICU patients. Incidence of Delirium (hypoactive, hyperactive, mixed) Pre-existing dementia Hypertension History of alcoholism High severity of illness at baseline Coma Benzodiazepine use • 80% of mechanically ventilated patients • 25% of hospitalized patients with chronic medical conditions • 40% HIV patients • 50% post-operative patients • 81.7% ICU survivors Risk Factors • • • • • • Treatment of ICU Delirium delirium in adult ICU patients. • There is not sufficient evidence to determine if haloperidol reduces the duration of in ICU patients, however they have no impact on mortality or length of ICU stay. • Atypical antipsychotics, such as quetiapine, may reduce the duration of delirium • MOA: Blocks dopaminergic and serotinergic receptors in the brain and also has histamine-blocking and alpha-blocking effects. • In a small prospective, randomized, double-blind, patients who were being treated with haloperidol for delirium and additionally received quetiapine had a reduced duration of delirium. − Quetiapine: 50 mg q 12 hrs and could be increased by 50 mg every 24 hrs if needed up to 200 mg q 12 hrs − Patients could receive IV haloperidol 1-10 mg q 2 hrs PRN • More conservative dosing of quetiapine starting at 12.5-25 mg q 12 hours may be appropriate. • Antipsychoitcs should be avoided in patients are risk for QT prolongation. Haloperidol (Haldol) Quetiapine (Seroquel) • MOA: Blocks dopaminergic receptors in the brain; also has some alpha-blocking and anticholinergic effects • Repeat bolus doses every 30 min until calm and then administer 25% of the maximum dose ever 6 hours − Mild agitation: 0.5-2 mg IV − Moderate agitation: 2-5 mg IV − Severe agitation: 10-20 mg IV Ziprasidone (Zyprexa) • MOA: Blocks dopaminergic, serotinergic, alpha-1 and cholinergic receptors • In a small, randomized, double-blind, treatment of delirium with either haloperidol, ziprasidone or placebo resulted in a similar number of days alive without delirium or coma. Ziprasidone 40 mg q 6-12 hrs − Haloperidol 5 mg q 6-12 hrs vs. 3 Sedation and Delirium Assessments: A Two Step Approach Step One: Sedation Assessment (RASS) If RASS is –4 or –5, then Stop & Reassess patient at later time If RASS is above –3 through +4 then Proceed to Step 2 Step Two: Delirium Assessment (CAM-ICU) And Feature 2: Inattention And Or Feature 4: Altered Level of Consciousness Feature 1: Acute onset of mental status changes or a fluctuating course Feature 3: Disorganized Thinking = Delirium Ely. JAMA 2001; 286: 2703-2710. Ely. Crit Care Med 2001; 29: 1370-1379. Positive if patient’s current level of consciousness is anything other than alert (RASS other than “0” at time of assessment). Feature 4: Altered Level of Consciousness Positive if ASE score is less than 8. Assess using the Attention Screening Examination (ASE) – Letters or Pictures. Attempt ASE Letters first. If patient is able to perform this test and the score is clear, record the score and move to Feature 3. If patient is unable to perform this test or the score is unclear, perform the ASE Pictures. If you perform both tests, use the ASE Pictures results to score the Feature. ASE Letters: Auditory / Random Letter “A” Test Directions: Say to the patient “I am going to read you a series of 10 letters. Whenever you hear the letter ‘A’, indicate by squeezing my hand.” Read letters from the following list in a normal tone: S A V E AHAART Scoring: Errors are counted when patient fails to squeeze on the letter “A” and when patient squeezes on any letter other than “A”. ASE Pictures: Visual / Picture Recognition - Directions and scoring are located on picture packet. Feature 2: Inattention Copyright © 2002, E. Wesley, Ely, MD, MPH and Vanderbilt University, all rights reserved Feature 1: Acute Onset or Fluctuating Course Positive if either question is answered yes. Is there an acute change from mental status baseline? Did the patient’s mental status fluctuate during the past 24 hrs as evidenced by fluctuation of sedation scale (RASS), GCS or previous delirium assessment? Feature 3: Disorganized Thinking Positive if the combined (Questions + Command) score is less than 4. Yes/No Questions: Use either Set A or B, alternate on consecutive days if necessary. Set A Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two pounds? Can you use a hammer to pound a nail? Set B Will a leaf float on water? Are there elephants in the sea? Do two pounds weigh more than one pound? Can you use a hammer to cut wood? Score: Patient earns 1 point for each correct answer out of 4. Command: Say to patient: “Hold up this many fingers” (examiner holds two fingers in front of the patient) “Now do the same thing with the other hand” (not repeating the number of fingers). Score: Patient earns 1 point if able to successfully complete the entire command. 061 4 Pain in the ICU Fentanyl Drug Yes No Active Metabolite 5-10 min 1-2 min Onset of Action 2-3 hr 3-4 hr 2-4 hr Elim t ½ 2-6 hr 2-4 hr 0.5-1 hr Duration of effect Causes of Pain • Limited positioning at rest, endotracheal tube, post-operative / postprocedural pain Incidence of Pain in the ICU • In patients discharged from the ICU but remaining in the hospital, 82% remember pain or discomfort associated with ET tube and 77% remembered experiencing moderate to severe pain during their ICU stay. • Six months after discharge, 38% of patient still recalled pain as their most traumatic ICU memory and 18% were at risk for development of PTSD. Opioids are first line for management of pain. • All available opioids when titrated to similar pain intensity endpoints are equally effective. Agent selection is based on pharmacological properties and potential for adverse drug reactions • MOA: opioids bind Mu, Kappa and Delta receptors in CNS • Opioid Class Adverse Effects − Potent respiratory depression (dose-dependent) − Hypotension and vasodilation − Decreased intestinal motility (dose-dependent) − Histamine release (morphine) Morphine 5-15 min Hydromorphone • Similar duration of action to morphine, however it has no active metabolite • Not associated with histamine release No Morphine • Accumulation with hepatic/ renal impairment • Only use in hemodynamically stable patients • Can cause venodilation (direct effect, histamine release, neural medication) and hypotension Hydromorphone Fentanyl • Preferred for hemodynamically unstable patient • 50-100x more potent than morphine • 7000x more lipophilic than morphine • Accumulates during prolonged administration Adjunctive pain medications can be used to reduce opioid requirements and to reduce incidence and severity of opioid related side effects. • For neuropathic pain: gabapentin or carbamazepine in addition to iv opioids can be considered for treatment For non-neuropathic pain: IV acetaminophen and NSAIDS can be used in addition to opioids • Propofol: • • • • • • • • • • • • 9 Adverse Effects Strong respiratory depressant Hypotension (dose-related) Longer recovery after > 12 hr infusion Hyperlipidemia, TGs (10% so bean oil) Risk of infection Infusion related (administer centrally) Propofol syndrome (hypotension, pancreatitis, brady cardia, lactic acidosis, rhabdomyolysis, renal failure) MOA: CNS depression by agonism of GABA and blockade of NMDA receptors General anesthetic with sedative / hypnotic properties but no analgesia Produced less amnesia than midazolam in comparative studies Predictable time to sedation and recovery Studies comparing propofol with midazolam showed shorter time to extubation with propofol.Has been used to sedate neurosurgical patients to reduce elevated ICP, decrease cerebral blood flow and metabolism Pharmacokinetics • Onset: 30 sec after bolus • Duration 3-10 min • Vd: extremely lipophillic with a large Vd leads to accumulation with high doses, prolonged infusions and obese patients Protein bound: 97.9% Initial t ½: 2-8 min Terminal t ½: 300-700 min No changes in kinetics with renal or hepatic dysfunction • • • • Benzodiazepines: Lorazepam (Ativan), Midazolam (Versed), Diazepam (Valium) • MOA: bind GABA receptors in CNS and increase affinity for GABA • Dose dependent sedation / amnesia • Do not provide any analgesia, although does have opioid sparing effects by moderation of anticipatory pain response • Highly protein bound and hepatically metabolized • Durations of action are dependent on lipid solubility, volume of distribution, protein binding and elimination half-life • Active metabolites may prolong duration and elimination − 1-hydroxymidazolam is renally eliminated and accumulates in renal failure • Propylene glycol toxicity (diluent IV lorazepam) with high doses (>10 mg/hr) • Drug interactions − Enhanced elimination: cimetidine, erythromycin, isoniazid, ketoconazole, metoprolol, and propranolol − Reduced elimination: rifampin and theophylline 5.58 9.57 2.23 Receptor Affinity 0.44 0.48 0.79 1.00 0.71 Lipid Solubility 1.54 Short term: 3-12 hr Long term: 50+-18.6hr 8-15 hr 36-90 hr 20-70 hr 1-4 hr (up to 11) Elim t ½ 5-10 min 1-2 min 15-20 min 2-5 min Onset of Action Active Metabolite 1.64 n/a 1.8-3.1 hr Drug Diazepam None Desmethyldiazepam n/a n/a a1-OH midazolam Lorazepam None n/a Midazolam Propofol None 2-5 min Dexmedetomidine 062 8 Indications for Sedation Sedation in the ICU Optimizing Sedation and Analgesia • Prevent self-extubation drawal • Treat EtOH / substance abuse with- ronment • Allow sleep in uncomfortable envi- ated with procedures • Reduce oxygen consumption • Decrease stress response associ- lower airway pressures • Suppress spontaneous ventilation to • Improve tolerance of entotracheal tube and mechanical ventilation • Prior to initiation of sedation / analgesia, differentiate between anxiety, pain and / or delirium and treat reversible causes prior to initiation of sedation and analgesia. • Protocol driven with lighter sedation target • Analgesia first approach or analgesiabased sedation Use non-BZD sedatives when possible Employ “co-sedation” Perform daily interruptions of sedation Delirium prevention • • • • Dexmedetomidine (Precedex ®) 1-2 mg q 0.5-2 hr 0.02-0.08 mg/kg q 0.5-2 hr — — Intermittent IV Dose — 2 mg/hr 0.04-0.2 mg/kg/hr 5-10 mcg/kg/min Do not bolus 0.2-1.4 mcg/kg/HOUR Max reported 2.5 mcg/kg/hr Infusion Dose Range • Highly selective alpha-2 adenroreceptor agonist that produces sedation, anxiolysis and partial analgesia by central binding at the locus ceruleus and spinal cord • Boluses are associated with hypotension − Start infusion at 0.2 mcg/kg/HOUR and titrate to desired level of sedation every 20-30 min − Onset of action without bolus: 20-30 min • FDA Indication: use as a sedative for patients undergoing mechanical ventilation in the ICU and as a sedative prior to and / or during surgical or other procedures of non-intubated patients • Patients are sedated when undisturbed and arouse with gentle stimulation − “cooperative sedation” • In comparative studies, dexmedetomidine was shown to provide better sedation than lorazepam and equivalent sedation to midazolam and propofol. Additionally, dexmedetomidine was associated with decreased mechanical ventilation days and hospital length of stay compared to midazolam and equivalent ventilation days and hospital length of stay compared to propofol. • Adverse effects: significant hypotension and bradycardia • Use caution: heart block, EF<30%, liver failure, hypovolemia and hypotension Midazolam 0.03-0.1 mg/kg q 0.5-6 hr 1 mg/hr 0.01-0.1 mg/kg/hr Dexmedetomidine Diazepam 0.5-2 mg q 2-6 hr 0.02-0.06 mg/kg q 2-6 hr Propofol Lorazepam 25-50 mcg Starting bolus 25-50 mcg q 0.5-1 hr 0.35-0.5 mcg/kg q 0.5-1 hr 2-4 mg q 2 hr — 2 mg/hr Starting infusion Drug 2-4 mg 0.2-0.6 mg q 2 hr Intermittent IV dosing Fentanyl 0.4mg 25 mcg/hr Morphine Hydromorphone Dosing 1000 mg q 6 hr Max: 4 g/day Elim t ½ 2 hr Initial: 100 mg TID Maintenance: 900-3600 mg/day in 3 divided doses Onset IV Acetaminophen 5-7 hr Drug PO Gabapentin N/A Initial 25-65 Initial: 50-100mg BID hrs then 12- Maintenance: 100-200 mg q 4-6hr 17 hr Max: 1200 mg/day IV Acetaminophen IV Ketorolac • IV achieves higher plasma levels compared to PO resulting in higher CNS levels, superior analgesic effects and longer duration of effect • Avoids first pass metabolism: lower hepatic exposure • Efficacy data: post-operative pain vs. placebo and as effective as 30 mg of ketorolac or 10 mg morphine • Potential opioid sparing effect 10 min 2.4-8.6 hr 5 NSAIDs • Avoid NSAIDs in the following patients: renal dysfunction, GI bleeding, platelet abnormalities, concomitant ACE-inhibitor therapy, CHF, cirrhosis, asthma • Contraindicated for treatment of perioperative pain in CABG 5-10 min PO Car4-5 hr bamazepine IR Gabapentin • Common side effects: sedation, confusion, dizziness, ataxia • Adjust dose in patients with renal failure • Abrupt d/c associated with drug withdrawal syndrome and seizures 30 mg then 15-30 mg q 6 hr Max: 120 mg/day x 5 days Carbamazepine • Side effects: (common) nystagmus, dizziness, diploplia, lightheadedness, lethargy; (rare) aplastic anemia, agranulocytosis, Stevens-Johnson syndrome, toxic epidermal necrolysis with HLA-B1502 gene • Multiple drug interactions due to hepatic enzyme induction. 063 6 7 064 I. Specific Agents Norepinephrine Combined α and β agonist (α > β) , more potent than dopamine MAP, SVR Little effect CO/Ci or PCWP; Increased HR Increased UOP due to increased perfusion It does not worsen, and it can improve tissue oxygenation in septic shock patients Adverse effects _ Tachyarrhythmias _ In the context of hypovolemia there is increased vascular resistance and renal ischemia DOC in septic shock Wide dosage range: 0.2 – 1.3 mcg/kg/min; the highest dose reported: 3.3 mcg/kg/min (most pts stop responding far earlier) Vasopressin Potent vasoconstrictor (acts on vascular V1 receptors when blood pressure compromised) _ It has limited effect in normal subjects, but there is a marked increase in BP when sympathetic nerve function is impaired _ More potent than Phenylephrine and Norepinephrine _ Effective in acidosis/hypoxia _ Used in small studies in patients with refractory septic shock _ Other effects: Na+ and H2O retention, cortisol production SBP, MAP, SVR May renal output (increased perfusion pressure, hydrostatic pressure). PCWP or oxygenation were not adversely affected (reports) Vasopressin administration increases effectiveness of simultaneous catecholamine therapy and may allow for weaning and eventual catecholamine discontinuation Vasopressin levels increase during early septic shock and decrease over time to below normal -> vasopressin deficiency during late septic shock Dosage range: 0.01 – 0.1 units/min (average: 0.04 units/min) Adverse effects _ In patients with CAD -> Increase in myocardial oxygen consumption -> may precipitate an MI _ Impairment of blood flow to splanchnic system, stress ulcers, bowel ileus and malabsorption 2 Dopamine Precursor of norepinephrine and epinephrine (conversion might be impaired in shock states) 065 CO/Ci (improves ventricular contractility and HR), MAP, SVR Dose dependent adrenergic effects At low doses acts on the DA1 receptors causing renal vasodilatation. This dose response relationship has not been confirmed in critically ill patients (“renal dose dopamine”) Adverse effects _ Tachyarrhythmias _ PCWP (pulmonary vasoconstriction), increase in pulmonary shunt There is limited improvement when going beyond the 20 mcg/kg/min dose Dobutamine Synthetic cathecolamine selective for β1, mild β2 and vascular α1 activity-> positive inotrope without vasoconstriction in CO/Ci is greater than with dopamine No effect on DA receptors The increased contractility leads to reflex reduction in sympathetic tone -> SVR Used to increase CO/Ci in septic and cardiogenic shock patients Phenylephrine Pure α1 agonist MAP, SVR Does not impair Ci, PSWP Reflex bradycardia has been reported, usually no change in HR Limited studies in septic shock patients It can cause severe peripheral vasoconstriction Epinephrine Combined α and β agonist MAP, Ci, SVR, HR Used as last resort Adverse effects _ Tachyarrhythmias _ Severe vasoconstriction of splachnic and renal beds _ Increases regional and systemic lactate concentrations Andreea E. Popa, Pharm.D. Critical Care Clinical Pharmacist 066 Rheumatology Lab testing In general, remember that rheumatologic diagnosis relies more on history and physical than lab tests. A patient with a very low pretest probability and a positive test still has a low posttest of probability of having the disease of interest. ANA: can be obtained as a screen where perinuclear staining is visualized using immunoflorescence, OR a panel of specific antibodies. Generally the screening visualization test has fewer false positives but gives less detailed or specific information. At UH: This can be ordered as screen only (ANA without reflex ENA), screen with reflex to panel (ANA with reflex ENA), or screen + panel (ANA with automatic ENA). Generally you will be ordering the screen with reflex to panel (ANA with reflex ANA). Only order the screen with automatic panel in situations where you have a VERY high pretest probability – typically you will only be doing this at rheum’s recommendation. At the VA: this comes as ANA multiplex only (no staining, specific antibiodies only). This means you get a panel of ~12 antibodies WITHOUT the screening stain test. The panel alone has at least one positive antibody in >20% of the women in the general population, a number which increases with age to 40-50% by age 65 – be careful about ordering about this in older patients with symptoms of fibromyalgia as you are likely to get a false positive and end up incorrectly diagnosing the patient as lupus! ESR/CRP Sensitive and nonspecific. -CRP can be ordered as standard assay reported in mg/dL (useful for assessing gross abnormalities of inflammation in rheum patients) and the high sensitivity assay reported in mg/L (useful in coronary risk assessment). At UH, ordering CRP will order the standard assay (mg/dL) but at VA ordering CRP orders the high sensitivity assay in mg/L, so remember to divide your result by 10 before interpretation (a CRP of 10 at the VA is normal!) -ESR: Upper limit of normal can be estimated by Age/2 in men, and (Age+10)/2 in women. ANCA (anti-neutrophil cytoplasmic antibody) : Can be useful in assessing suspected vasculitis. As with ANA you typically will order the ANCA as an immunofluorescence assay (sensitive, not specific) and if positive will give you the staining pattern (p for perinuclear, c for cytoplasmic). ELISA can also be performed for the specific targets of interest, PR3 (proteinase 3) and MPO (myeloperoxidase), and these may be ordered to follow up a positive ANCA. Rheumatology may have you order the ANCA along with the specific antibodies (anti-PR3 and anti-MPO) in patients with a very high pretest probability of vasculitis. -C-ANCA is when staining is noted more prominently in cytoplasm; this is more commonly (but not exclusively) associated with PR3, and more commonly associated with GPA (Wegener’s) 067 -P-ANCA is a pattern of perinuclear staining, more commonly associated (but again not exclusively) with MPO. More commonly associated with MPA (microscopic polyangiitis) and Churg Strauss. RF and anti-CCP Tested in suspected RA and can be helpful in differentiating RA and psoriatic arthritis or other conditions. Up to 20% of patients with RA are seronegative (negative for both antibodies.) Seronegative RA tends to be limited to joint involvement, and has fewer systemic effects. RF is an IgM specific for Fc portion of IgG. Titers can correlate with disease activity. Can also be positive in diseases such as connective tissue disease, B cell lymphomas, chronic Hep C and SBE. Anti-CCP more specific than RF and portends a worse prognosis. Complement levels (C3, C4) In the context of rheumatology, most useful for assessing activity of glomerulonephritis in SLE, in which levels will be low. Low generally in diseases where immune complexes are being formed, including Sjogren’s, mixed cryoglobulinemia, and MPGN. Rheumatologic emergencies and urgent clinical situations C-spine instability in patients with RA: consider urgent C-spine imaging (MRI with GAD preferred) and urgent Spine surgery consult in patients with RA or spondyloarthropathies who develop neurologic symptoms; may be associated with atlantoaxial instability/subluxation resulting in cord compression Scleroderma renal crisis: Consider in a patient with systemic sclerosis (usually recently diagnosed) with acute onset of renal failure without hx of CKD. Assocated with abrupt onset of HTN. UA normal. Associated with MAHA and sometimes difficult to differentiate from TTP/HUS. Pathophysiology related to infrarenal renal artery stenosis. Treat with captopril as first-line, but monitor creatinine closely. Pulmonary-renal disease -> can be rapidly progressive. Differential includes GPA, MPA, endocarditis, Churg-Strauss, Goodpasture’s. Send ANCA and anti-GBM. Initial lab workup should include ANA, HIV, LFTs, C3/C4, UA, hepatitis panel to exclude other causes. Low threshold for tissue biopsy and early initiation of immunosuppressive therapy. Visual loss with Giant Cell Arteritis (Temporal Arteritis) – consider in older patient (particularly with history of polymyalgia rheumatic) with visual loss and headaches, jaw claudication, fevers or elevated inflammatory markers. Dx with temporal artery biopsy and treat with pulse solumedrol if visual loss present. HLH/MAS: Consider in critically ill patients with unexplained fevers, rash, lymphadenopathy. Labs notable for cytopenias and profoundly elevated ferritin. CRP elevated but ESR may be low. Consider macrophage activation syndrome in young adult 068 with hx of juvenile idiopathic arthritis or Adult Still’s. Consult rheum and hem/onc for consideration of bone marrow biopsy. Gout management in primary care Gout occurs due to an immune reaction to urate deposits (tophi.) Uric acid precipitates at levels greater than 6.8mg/dL at body temperature, and closer to 6 at the temperature of the extremities. Therefore while uric acid level is >6mg/dL, the patient is in positive crystal balance. Goal of therapy should be to maintain uric acid <6mg/dL while preventing flares. You can manage gout as a primary care physician! Treat with allopurinol - start 100mg daily x 2 weeks to assess allergic response and avoid precipitating gout flare by dropping uric acid level too quickly. Then begin to titrate up to achieve goal uric acid level. Allopurinol dosing is no longer based on renal function. In 1-2% of patients who are allergic to allopurinol, use febuxostat. Treat with colchicine 0.6-1.2 mg daily to prevent flares until uric acid <6 for 6-9 months, then trial weaning off – may need to resume if patient has recurrent flares. Currently at the VA colchicine can only be ordered by rheumatology, but this will change once colchicine goes back off patent. Acute flare: Treat with colchicine 1.2mg followed by another 0.6mg 1 hour later. Use NSAIDS such as indomethacin along with colchicine to treat acute flares. Pseudogout (calcium pyrophosphate deposition disease, CPPD) is managed similarly except for uric acid lowering. Use colchicine or NSAIDS for flare prophylaxis; prednisone may be used for flares. Osteoarthritis management in primary care Osteoarthritis management: no pharm tx to prevent progression, therapy is aimed at reducing symptoms and disability. Mild disease: weight loss, exercise, knee braces, PT, acetaminophen, NSAIDS if failure of acetaminophen or evidence of inflammatory disease, topical NSAIDS (voltaren cream), capsaicin cream Moderate or refractory disease: In addition to above therapies: can trial injection of triamcinolone (40mg for large joints) -> does not halt progression, leads to median 3 weeks of symptom reduction. In patients with failure of above therapies can refer to rheumatology for trial of intraarticular hyaluronans (Euflexxa) though data do not necessarily show strong benefit. 069 Severe disease: cautious use of opioids; consider pain management referral; refer to orthopedics for consideration of joint replacement 070 A classification schema with common presentations of rheumatologic disease: Seronegative spondyloarthritis: common features include involvement of axial skeleton, enthesitis (inflammation at tendon insertion site), uveitis, association with HLA B27, asymmetric peripheral disease. Documentation of HLA-B27 positivity can be supportive but is extremely nonspecific. Elevated inflammatory markers but by definition no specific antibodies. Ankylosing Spondylitis Psoriatic Arthritis morning stiffness, SI tendernes, enthesitis Can be similar to RA but involves DIP, may have prominent axial involvement, dactylitis, typical rash of psoriasis but arthritis may precede dermatologic disease Reactive Arthritis IBD associated spondyloarthritis asymmetric, mono or oligoarthritis in large joints 1-4 wks after GU or GI infection Clinically indistinguishable from AS except for associated IBD. May not correlate with activity of intestinal disease! 071 Connective tissue disease: Common features include arthritis/arthralgias, can cause overlap syndromes (also referred to as MCTD, mixed connective tissue disease, associated with anti-RNP) SLE Most common sx Constitiutional symptoms, Rash (malar rash, discoid lupus, photosensitivity), arthritis but arthralgias more common, glomerulonephritis, serositis (pleural and pericardial), verrucous endocarditis (libmansacks), thromboembolism associated with antiphospholipid antibody, wide spectrum of CNS and peripheral neurologic manifestations, keratoconjunctivitis sicca, cytopenias, lymphadenopathy and splenomegaly. Common anemia, Lab thrombocytopenia, findings leukolymphopenia, low complement, elevated inflammatory markers. + ANA with variety of other + autoantibodies inc to dsDNA, Smith, Ro, La, histone, RNP, ribosomal. False + VDRL. Systemic Sclerosis, Scleroderma, CREST Characteristic is thickened, sclerotic skin leading to progressive immobility and disability. Spectrum of disorders - limited cutaneous systemic sclerosis, cutaneous with systemic symptoms, CREST syndrome (Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia). Systemic symptoms include ILD, pulmonary vascular disease, renovascular disease, pericardial or myocardial involvement anti-centromere (limited cutaneous scleroderma), anti-SCL 70 (diffuse systemic sclerosis). 072 Sjogren's dry eyes, dry mouth, parotid enlargement, arthritis, interstitial nephritis, serositis, increased lymphoprolife rative disorders ANA, +RF, anti-SSA, antiSSB Polymyositis and dermatomyositis Middle age, presents with progressive proximal muscle weakness. Dermatomyositis associated with gottron's papules (over PIP and MCP) and heliotrope rash elevated CK, aldolase, AST. +ANA typical, occasionally +RF. Anti-Jo associated but usually negative. Dx testing includes EMG and muscle biopsy. RA PIP and MCP without DIP involvement. Also wrists, knees, ankles, MTPs, C-spine. Associated with pleural disease, interstitial lung disease. Felty syndrome = neutropenia, RA, splenomegaly Anemia, Rheumatoid Factor (titer correlates with disease activity), antiCCP (correlates with more severe disease) Tx SLE Systemic Sclerosis, Scleroderma, CREST Sjogren's Polymyositis and dermatomyositis RA NSAIDS, steroids, hydroxychloroquine; cyclophosphomide for acute major organ involvement (CNS, renal); MMF or 6MP for nephritis, MTX for joint disease Treatment based on organ involvement; SKIN: immunosuppressive therapy not very effective for skin thickening. MTX or MMF to start. Pruritis may be tx with steroids, antihistamines, capsaicin, phototherapy. RENAL: ACEi. LUNG: cyclophosphamide, pulm vasodilators. JOINT: steroids, hydroxychloroquine, MTX. GI: promotility agents, PPI NSAIDS, steroids; give eye drops and supportive care for sicca symptoms. Immunosuppre sive therapy depending on systemic involvement. Hydroxychloroq uine for mild arthralgias, MTX for refractory symptoms. Biologics if severe steroids, methotrexate or azathioprine, cyclophosphamide, IVIG Steroids, methotrexate is the workhorse, leflunomide, can use sulfasalazine. Biologics (etanercept, adalimumab, infliximab) typically added if methotrexate does not eradicate symptoms. Rituximab increasingly used for refractory disease 073 Vasculitis: Common features include rash (classically palpable purpuric rash, can be variable), common renal involvement, high degrees of inflammation. Small Vessel Churg Strauss Henoch Schonlein Purpura Vasculitis from RA, SLE, or Sjogren's Cryoglobulinemia Common symptoms and associations Pulm, renal, ENT involvement. Initial lab workup should include ANCA, as well as ANA, HIV, LFTs, C3/C4, UA, hepatitis panel Accelerating asthma/atopy in adulthood, eventually followed by vasculitic symptoms including lung, skin, kidneys, neurologic systems and others. Hematuria, Vasculitis rash on lower extremities, Abd pain, orchitis, Arthralgias/Arthr itis. Typically in children but can be seen in younger adults Distal arteritis with digital ischemia, livedo reticularis, purpuric rash. Pericarditis, mesenteric ischemia Associated with lymphoproliferative disorders or chronic HCV. Symptoms consistent with small vessel vasculitis including renal involvement, arthralgias, vasculitic rashes, neuropathy Lab findings ANCA+ in 90% (typically CANCA in GPA, P-ANCA in MPA) peripheral eosinophilia, elevated IgE, PANCA against MPO but can be C-ANCA hematuria, proteinuria cryoglobulins (must be taken to lab immediately to avoid false negative), +RF, dec C4 with normal C3 Dx Biopsy from affected tissue; differentiating factor is LACK of granulomas in MPA Biopsy in characteristic clinical context Clinical clinical, biopsy and labs are supportive Tx Steroids, cyclophospham ide. Bactrim to prevent respiratory infections for GPA Steroids, cyclophosphamide Supportive, steroids only for persistent or severe proteinuria or renal impairment GPA (Wegener's) and MPA 074 steroids, cyclophospha mide, treat underlying connective tissue disease Most important treat underlying disease; can use steroids, others for significant organ involvement Vasculitis continued Common symptoms and associations Lab findings Dx Tx medium vessel PAN small and medium Behcet's large vessel GCA Takayasu headache, visual loss, jaw claudication. Very commonly associated with polymyalgia More common in young Asian women. Constitutional symptoms follwed by aortitis and other large central arteries. HLA B51 associated. leukocytosis, increased ESR, associated with elevated ESR and HBV, CRP occasionally pANCA elevated ESR, CRP Clinical, bx of ulcers can be helpful Clinical; biopsy, angiography temporal artery can be bx supportive or confirmatory vascular imaging Steroids, cyclophospham ide. Antiviral Steroids therapy if associated with HBV steroids, MTX, antiplatelets oral and genital ulcers are classic, may also have variety of systemic involvement including derm and optho involvement. Associated with Middle Eastern and South/Central Asian ethinicities azathioprine, colchicine, steroids, other DMARDS 075 Constitutional (fevers, weight loss), purpuric rash or livido reticularis, GI, renal, arthralgias/art hritis, myalgias, peripheral neuropathy, orchitis Hematology/Oncology (Ratnoff/Weisman) Ratnoff and Weisman are the Heme/Onc services. Ratnoff is staffed by an oncology attending, Weisman by a hospitalist. The service is a mix of direct admit from heme/onc clinics, ED, and outside hospital transfers. Many of the straightforward patients (admit for chemo, symptom control…) go to the Berger hospitalist/NP service, so the resident teams are left with patients who are often quite sick and bouncing between the floor and MICU. Team Structure: 1 attending, 1 senior resident, 2 interns. Occasional AI/MS3 Cap: 8 patients per intern (lower than other UH services), team cap increases with AI Admission guidelines: Short: 2 NF’s or ICU transfers prior to 1PM (none if clinic, off during weekend). Medium: 2 admissions prior to 4PM. Long: 3 by 7PM. Namesakes: In 1974 Oscar Ratnoff warned in the Annals of Internal Medicine that new pooled factor from many donors was associated with increased rates of hepatitis in hemophilia patients, and that the explosion in pooled factor over cryoprecipitate could cause significant harms. Again at the precipice of the HIV epidemic, he warned that explosive rates of HIV in hemophiliacs (>50% by 1984) was related to the pooled factor, and pleaded with industry and the CDC to use hepatitis B screening before accepting blood and plasma donations. Far ahead of his time, and swimming against the tide of huge corporate interests, he was ridiculed and ignored. By the 1990s, when the science finally became obvious to all, northern Ohio had some of the lowest rates of hepatitis and HIV among hemophiliacs in the country. As a fellow at Case Western, Russell Weisman worked with an OB/GYN fellow to define hemolysis as a critical component of the HELLP syndrome in pregnant women. Febrile Neutropenia: ANC<500 and T>38.0x1 hr (or >38.3 once). (Both UH and VA list ANC, but you need to use the multiplier 1000: 1.3 at the VA is actually 1300. If in doubt, multiply WBC by percent neutrophils. 1.Culture. 2 sets of blood cultures STAT (at least 1 from every port and central line, and one additional peripheral. The second is vital, will tell you if Coag Neg Staph is a contaminant and tell you if line is infected and needs removed), UA/UCx. If making sputum, cx it. If diarrhea, cx and send for C diff. 2. Source? Get a CXR (2 view). Push on the belly (neutropenic enterocolitis? sick pts can develop cholecystitis even if they came in for something else). 3. Get a complete set of vital signs. Is the patient still stable on the floor? Could the fever be from something else (these pts often get PEs and some PEs present with fever) 4. Cover Broadly: Staph, pseudomonas both in play here. Options: Vancomycin is sometimes needed for MRSA (if allergic or hx of resistance, daptomycin), our patients often have enough MRSA risks to buy them a couple days of vanc until the source becomes clear but this isn’t always needed. Most important is broad coverage with an gram negative/antipsuedomonal agent (piperacillin/tazobactam, cefepime all work here…if penicillin allergic meropenem has less cross reactivity and aztreonam is safe but you start to lose pseudomonas). If you’re thinking about gentamicin or other aminoglycosides you should run the case by a senior resident. If the patient is either in 076 the MICU or looks like they’re heading there, add antifungals (micafungin, not fluconazole). If stable and febrile after 5 days, consider voriconazole. 5. In the VA there is a neutropenic order set (will have diet, precautions, abx options, some culture orders. Check that everything you want is ordered). At UH it’s individual orders for neutropenic diet and neutropenic precautions.. At the VA all CBC’s have a diff, at UH you need to specify the lab with a differential. 6. Was the patient already on abx? If so ensure they are on appropriate coverage as above. Still resend cultures (may have better chance of catching transient bacteremia during fever). 7. Check past cultures to ensure the above applies to your patient (in CPRS under labs check the micro section for recent bugs, at UH use portal to look at recent blood/urine/sputum cultures). Adjust abx as needed. New neutropenic fever will significantly alter the day team’s work, if you are covering the patient as a NF write a clinical event note . Sickle Cell Admission: At UH use Portal to look at the most recent heme note and to see if the patient has a care path (if so it will be near the top of portal). Use OAARS to check narcotic use and if patient is filling with multiple providers/systems. The most challenging aspect of admitting a patient with sickle cell disease is that routine admissions and life threatening admissions both often involve pain. Fluids • hypovolemic: Normal Saline @ 300 - 500 mls/hr until patient is euvolemic. • euvolemic: D5W1/2NS at 75-125 ml/hr or consider oral rehydration alone if they’re tolerating Laboratory/Radiology All patients on admission: • CBC, retic, LDH, CMP, CRP, ua, Women: urine beta-HCG • Some patients on admission: blood culture, urine culture, CXR • If % of Hgb S subtypes needed (severe crisis, considering exchange transfusion) order “hemoglobin identification” at UH and “hemoglobin electrophoresis” at VA • Use labs drawn on a clinic day as baseline, not labs during their last hospitalization Transfusions • Transfuse PRBC’s if the Hgb drops >2 g below baseline. • Transfuse PRBC’s for symptomatic anemia i.e. shortness of breath, dyspnea on exertion or orthostasis. Sickle cell crisis is NOT a symptom of anemia. • Many patients chronically have Hgb around 8. Hgb<7 is not necessarily an indication to transfuse, but Hgb<5.5 probably is. • Never transfuse to >10 Pain Medications • All narcotic bolus doses should be given as IVPB (unless Carepath says differently). IV push narcotics give a euphoric high but not better overall pain control. Use outpt and previous admission dosing to judge how much the patient needs. • If there is no IV access, analgesics may be given IM or SQ. • If the patient is on chronic long acting narcotics, continue the same. • If no contraindications to NSAID such as renal dysfunction, GI bleed, PUD or GERD may add ketorolac 30 mg IV every 6 hrs x a maximum of 5 day. 077 • If pain not relieved with frequent PRN doses, transition to PCA. Avoid a basal dose. Respiratory • Incentive spirometry at bedside. Atelectasis and areas of hypoxia are dangerous in these patients. No O2 unless O2 sat<92% Ancillary Medications • Tylenol for fever >38 C. • For itching: diphenhydramine 25-50 mg po every 4-6 hrs or hydroxyzine 25-50 mg every 6 hours. No IV Benadryl unless extreme circumstances. Chronic Care • Ferritin concentration if not drawn in the previous 12 months • Echocardiogram if concern for acute chest or active cardiomyopathy (otherwise TTE done during crisis of little outpt use) • Pneumococcal, meningococcal and influenza vaccinations if not previously given Hydrea and Exjade • useful to know creat stable (for exjade) and neutrophils and retics/hgb aren’t unstable (hydrea). If Hgb<9 and Retic<100K, hold hydrea. If it’s unclear, ok to hold for 1st day or 2 of admission, the important thing is to discuss a discharge plan with the hematology fellow. Acute Chest • Hypoxia, chest pain, and new CXR infiltrate. Type and Screen, give O2, and talk with Heme and transfusion medicine about exchange transfusion and if pt needs MICU (may need line, closer monitoring, etc…). Control their pain. • Admission CXR may be normal is patients who subsequently develop Acute Chest • If Hgb<8, can use simple transfusion to bridge to exchange transfusion while waiting a MICU bed. Doesn’t remove the Hgb S, but does decrease percentage. 078 So you’re the intern on Weisman call. You’ve just admitted what you thought was an uncomplicated patient with pain crisis with your resident. The resident is gone and the routine labs you sent just come back, but they look off. Moreover, you’ve just gone back in to see the patient and that HR of 91 has creeped up to 108 and they just don’t look as good anymore. Here’s an approach to getting your patient what they need. Risk for acute crash: 1. See patient with senior resident (DACR/NACR if your resident is gone) 2. Type and Screen, control pain, ensure good IV access. 3. Consider urgent heme consult, MICU, exchange transfusion, stat imaging (discuss these with resident and/or fellow) Red flags for acute concern: Hgb>2 gram below bsln RR>22 or SaO2<92% New CXR infiltrate Worst HA of life (SCD prone to SAH) Localized new LUQ pain (spln sequest, life threatening) Fever “They just look sicker” Signs of physiologic problems: Hgb>1 gram below bsln ALT>2x bsln Absolute Retic>500k LDH>1.5xbsln WBC>1.5x bsln Creat>1.5 x bsln PLT 50% < bsln Talk about labs with your resident or another senior, make a plan. Decide if fluids/transfusion/abx indicated. Heme will need to see while inpatient. Signs of heavy disease burden: Acute Chest in last 2 mo Hx CVA TRV>3 on TTE Pts on Hydrea/Exjade Care Path not working These are chronically very sick patients. Consider heme consult with your resident if indicated. The Sickle Cell fellow’s pager is 32390. 079 Anticoagulation: The most frequent issues DVT ppx: 1) decide if the patient really needs it (if younger, expecting short hospital stay, walking…can avoid) 2)what to use (no lovenox in renal failure) 3)if there are any reasons not to use injectable AC (GIB? PLT<50? …just because an order set says AC is a good idea doesn’t mean it’s a good idea). Your main options are heparin SC 5000 q8 and lovenox 40mg daily. UH you must use the DVT risk order set (usually as part of admission, can just click ‘other’ for risk score to get 3 risk points and open up all your options) Therapeutic: lots of options beyond the scope of this guide. Know why they are on it and if they will need changed for some procedure (biopsy, coronary angio, other surg or IR procedure…) and how to plan for it (does Coumadin need held? Reversed? Will they need a heparin drip to bridge or are they ok off AC for a few days?). The issue will boil down to 1)why are they anticoagulated? And 2)Why do we need to hold AC? New Start/Bridging: Start with the indication (new PE needs AC more urgently than chronic A fib with CHADS=2). Decide if patient needs 1)Immediate AC with IV or injectable followed by maintenance oral AC. 2)new oral AC without injectable (rivaroxaban?). If you’ve decided to use a heparin drip to start Coumadin on a patient with new anticoagulation indication: • 1) Start both heparin gtt and Coumadin 5mg oral daily • 2)when INR>2 for 2 days, stop heparin gtt • 3)discharge on Coumadin single agent with AC clinic f/u (see below) A modified outpatient version of this can be done with enoxaparin, but insurance and approvals often get in the way Coumadin clinic: • At VA it’s easy: go to “Consults” in CPRS, click the indication boxes. Done. • At UH, my friend you are about to start a long journey. 1)Go to Residency Website, under UH resources print the Anticoagulation Clinic form. 2)Fill out this form 3)Find out which outpatient MD the patient will follow up with for AC 4)Fax the form to that provider for their signature 5)They fax it back (in theory) 6)Fax it to the AC Clinic for an appointment If this weren’t enough, you’ll need an attending to be responsible between discharge and first AC appointment. If the outpt provider says no, ask your attending. GI ppx: If hx of UGIB, PUD, or other risk factors, ensure on GI ppx (daily PPI) Hypercoagulability (this workup is often unnecessary inipatient, but if you’ve decided your patient needs it a few things to remember): 1) Prior to Heparin: Draw an extra blue top tube prior to starting heparin since heparin will interfere with assays for antithrombin III and the lupus anticoagulant. Protein C, S, anticardiolipin antibodies, homocysteine, prothrombin and Factor V Leiden mutations can be sent on pts on heparin. 080 2) Prior to Coumadin: Note that Proteins C + S are vitamin K dependent factors and will thus be lowered by warfarin therapy. 3) DNA-based tests (Factor V Leiden and Prothrombin 20210 mutation) can be done anytime. 4) Repeat abnormal tests in the future to document an accurate diagnosis. 5) Not every positive test is a diagnosis: keep in mind thrombosis itself (along with post op or severe liver disease) can decrease AT III, PC, PS. If the workup needs to start inpatient that’s fine, but most of these patient should have follow up with a hematologist as outpatients. The Anemia Workup (low production vs destruction vs sequestration) Start with some useful labs (CBC with diff, retic, LDH, type and screen, CMP to look at bili and for AKI of TTP, ferritin, iron studies). -Haptoglobin is ultrasensitive for hemolysis but not specific, LDH is more useful -Ferritin is an acute phase reactant, but only elevates with good iron stores. Harrison’s says over 200 and it’s not iron deficiency. Others use slightly higher or lower numbers. Essentially, once you’re much over 150-200, it’s not iron deficiency. Low Retics: Low MCV MCV wnl High MCV Fe def Acute Bleed B12 def High Retics: Elevated AIHA LDH/Bili Thalassemia Hemolysis Folate def MAHA ACD Sideroblastic Drug (hydrea ?, Dilantin ?) Liver Disease ACD PNH Liver Disease Sideroblastic Hypothyroid MDS Hypothyroid MDS Sickle Spur Cell/Hemoglobincell/HS/ opathy HE Liver Sequestration G6PD Normal Subacu Splenic LDH/Bili te Sequestrat Bleed ion -Spleen and Liver sequestration may also have elevated LDH/Bili, though often not as dramatic as would be see in hemolytic crisis. 081 Aplastic Getting a peripheral smear at UH and the VA Look at the Smear (schistocytes for TTP, blasts?, hypersegmented neutrophils…): At UH: Call heme tech at 45244 and ask for a peripheral smear on your patient. An hour later, go to 5th floor of Humphrey Building, turn left and lab door code is 13799*. Middle right is the heme tech station, they have a table with “slides for Docs”. Grab your patient’s slides and go look in the heme path room, back left. Take a senior resident the first time to show you around. At VA: Call 4085, ask for smear to be made. Go to basement on elevators between 4A and 4B, turn away from atrium side of hospital, you’ll see sign for lab. Ask at entrance for hematology lab (it’s the 3rd door on right in hall). Find a tech to show you the slides, there are two microscopes in the lab. -If you see several schistocytes per high powered field and TTP is on differential, remember the motto “Don’t let the sun set on TTP”. Wake up a hematology fellow. The Tumor Lysis Watchguard The idea behind tumor lysis syndrome is that killing large number of cancer cells releases large stores of intracellular ions and metabolites, which can be toxic in large quantities. Since it’s cell death that’s the cause, we worry particularly about high grade and highly chemosensitive malignancies (think leukemia, particularly with high WBC count, and high grade lymphomas). While it’s mostly liquids we think about, this is why tumor burden and chemosensitivity guide us and we often see small cell lung cancer patients admitted for tumor lysis observation. The Players: 1. Uric Acid-arthralgia, renal toxicity 2. Hyperkalemia-often earliest sign of TLS. Weakness and cardiotoxicity 3. Hyperphosphatemia-causes hypocalcemia 4. Hypocalcemia-parasthesias and tetany, may progress to AMS, szr, arrhythmia Goals: 1)Prevent 2)Recognize and treat quickly Prophylaxis: 1)start IVF (NS), if no CHF using 200/hr starting prior to chemo (increase to meet UOP goal). 2)allopurinol 200mg BID if normal renal fx Note: alkalinization of urine to maximize uric acid excretion is no longer routine, but may be recommended by a consultant Labs/Monitoring: BID RFP, phos, ionized calcium, uric acid, LDH, PT/PTT (DIC risk in these patients), urine output (keep it >100 cc/hr in avg adult, Pession 2011) Treatment: Increasing uric acid, potassium, hyperphos, hypocalcemia as above all indicate prevention failed. Rasburicase can rapidly lower uric acid, but is incredibly expensive. In some situations (like runaway hyperkalemia) patients may need MICU transfer and temporary HD. If it comes to rasburicase and/or HD discuss with your senior resident and the heme fellow. Source: Oxford Handbook of Clinical Haematology, ACP Resident Guide 082 Transfusions: Components, and troubleshooting The trend is towards less is more regarding transfusions, so decide if it’s really time to transfuse. The tools: 1) PRBC-most plasma removed (1 unit should increase Hgb 1 g/dl) -Leukoreduced: WBC removed, less antigenic. Use in cancer patients when you think they may need multiple transfusions, or pts with prior fevers with transfusion. -Washed: even fewer WBC, indications as above, more expensive -Irradiated: stem cells killed, lower GvHD risk -CMV negative: use in CMV negative pre or post-transplant patients(organ or BMT) 2)Platelets (a ‘6-pack’ is outdated terminology, we now use a single donor apheresis unit which should increase PLT 30-60k) 3)FFP: contains all factors (rapid warfarin correction, bleeding liver failure). Remember, many coag factors in FFP have ½ life <12 h (V, VII, VIII, protein C), so don’t load a nonbleeding patient with FFP this afternoon for a procedure that will be done tomorrow. 4)Cryoprecipitate-factor VIII, factor XIII vW factor, fibrinogen. Use in DIC, ask transfusion medicine for help with dosing. Transfusion Reactions: Acute Hemolytic Reaction: Fever with hemodynamic changes (usually rapid), heat along vein being transfused: think ABO incompatability. Stop the transfusion, send blood and patient samples to lab. Given Tylenol, Benadryl, methylprednisolone (125mg IV x1). Send LDH, smear, coombs, CBC. Delayed Hemolytic Reaction: fever, hemolysis, poor incremetation. Ab from prior transfusion/pregnancy (too weak to be detected in pretransfusion testing), when PRBC with antigen are transfused, hemolysis occurs. Send pt and transfusion samples as above (especially Coombs/DAT). Tx more supportive, tylenol for the fever and Benadryl if itching from the bilirubin. Often undiagnosed as it can occurs days or even weeks later and slowly. Fever without other vital sign changes: usually due to self reaction against donor WBC. Tx with tyenol and Benadryl. Unless protocol mandates stopping transfusion, keep it going and monitor patient. Allergic/itching: may also include laryngeal edema. Caused by reaction to foreign plasma proteins. Tx with benadryl, methylprednisolone. 083 Allergic/anaphylaxis: Rare but potentially deadly. Epinephrine IM, methylprednisolone 125mg IV, Benadryl IV, 1L NS. Call ENT for airway evaluation if indicated. If true anaphylaxis, MICU. TRALI: Shortness of breath, developing pulm edema on CXR. Supportive care, which may mean MICU if severe. TRALI is often mistaken for CHF (if your patient has grade 1 or 2 diastolic dysfunction and is now on a ventimask after 1-2 units, consider TRALI rather than HFPEF). Source: University of Michigan Department of Pathology and Oxford Handbook of Clinical Haematology HIT Pretest Probability (“The 4 T’s of HIT): 1. Thrombocytopenia (>50% decrease, and still >20k) 2. Timing: Occurs 5-10d after starting heparin, earlier if exposure in last 3 mo. 3. Thrombosis: new thrombus, or skin necrosis at site of SC injection 4. Other: is there another reason for decreasing plt? Sepsis? Drug? Workup: Anti-PF4 is sensitive, but less specific. Comes back early, if negative you can stop bivalrudin/argatroban (unless pretest probability stratospheric). Seratonin Release Assay just as sensitive but more specific, takes longer to come back. Treatment: If pretest probability moderate to high, stop the heparin, and start bivalrudin or argatroban (if renal failure, use argatroban) Cause: IgG Ab attacks multimolecular PF4/heparin complexes. Facts: Incidence higher with heparin than enoxaparin. Incidence greater in surgical patients. Sources: Oxford Handbook of Clinical Haematology, Ortel TL. Hematology Am Soc Hematol Educ Program. 2009;225-232. 084 Your first day on:! CARPENTER SERVICE! ! Carpenter is the infectious disease service. All* HIV patients are admitted to Carpenter. The service also carries patients with complicated infections (epidural abscess, severe sepsis, FUO) and occasionally general medicine patients with “an ID bent”.! ! *exception: HIV patients who also have cancer or ESRD may go to Ratnoff/Weisman or Eckel service (depending on which issue their chief complaint is related to). These patients will be followed by the Carpenter attending on service, NOT the ID fellows. ! !Team structure: 1 attending, 0-1 fellows, 1 senior, 2 interns, occasionally 1-2 AI, usually 1 MS3! Team cap: 20 patients ! Admission guidelines: 2 patients on short (by 12PM, must be NF or MICU transfer), 2 patients on medium by 4 PM, 3 patients on long by 7 PM! Namesake: C.J. Carpenter, former chief of medicine and infectious disease guru. Still practicing at Brown University. Dr. Salata was his last chief resident!! ! General pearls:! - look up vitals as you normally would, but keep in mind to look for the Tmax! - report back on all cultures on morning rounds! - know DAY of antibiotics (e.g. “day 5 of planned 7 day course”) and put a stop date in your daily note so you don’t forget when antibiotics need to stop! - consider narrowing antibiotics ASAP! ! NEED TO KNOW TOPICS:! ! SIRS/SEPSIS! ! SIRS: 2/4 “SIRS criteria”! • T > 38°C or T < 36°C! • HR > 90 bpm! • RR > 20 or PaCO2 < 32mmHg! • WBC > 12,000/mm3 or WBC < 4,000/mm3 or bands > 10%! Note: you can have SIRS criteria without an infectious etiology! Common examples include pancreatitis, VTE, cholecystitis. ! ! SEPSIS: SIRS + suspected source of infection! Check the following to evaluate for infection (in addition to your physical exam):! • CXR! • urinalysis (and urine culture)! • blood cultures! • consider CT a/p for intraabdominal infection! • consider Cdiff PCR for concurrent diarrhea! ! SEVERE SEPSIS: Sepsis + new end organ damage! Examples of end organ damage include:! • AKI ! 085 ! • troponinemia! • lactic acidosis! • hyperbilirubinemia! SEPTIC SHOCK: severe sepsis + hypotension not responsive to adequate fluid resuscitation ! Continue to bolus fluids as long as patient can tolerate; would consider adequate challenge at least 2-3L of NS or LR. If patient is in septic shock, consideration should be made for MICU transfer. ! ! MULTI ORGAN DYSFUNCTION SYNDROME (MODS):! Shock leading to organ failure. Patient should be in the MICU by this point. ! ! TREATMENT OF SEPSIS:! • Early UA/UCx, BCx, SpCx (if applicable), fluid cultures e.g. ascites (if applicable)! • OBTAIN CULTURES BEFORE ANTIBIOTICS! • Early administration of broad spectrum antibiotics! • Follow cultures and narrow antibiotics as needed! • Aggressive fluid resuscitation! • Aggressive monitoring (at least frequent VS, could consider CVC if in ICU)! • Could consider vasopressor agents (in ICU) if BP is not responsive to fluids! • Goals of care! • See MICU section for further information on the treatment of septic shock! ! COMMON ID CLINICAL SYNDROMES! ! MENINGITIS:! Presentation: fever, headache, nuchal rigidity (+Kernig and +Brudzinski signs), AMS (with concurrent encephalitis)! ! Etiology: S. pneumoniae, N. meningitidis, Listeria (in elderly), enteroviruses! ! Diagnosis: lumbar puncture! ! bacterial viral opening pressure high normal or slightly elev glucose very low normal protein high WBC 1000-500 0, PMNs ! fungal/TB normal to low normal/ high high 10-500, 10-500, lymphocytic lymphocytic Treatment:! bacterial meningitis: CTX 2g IV q12h + vancomycin 15mg/kg IV q8h for trough 15-20 + dexamethasone 0.15 mg/kg IV q6h +/- ampicillin 2g q4h (depending on risk for listeriosis)! • CTX will cover S. pneumoniae and N. meningitidis! 086 • vancomycin will cover CTX-resistant S. pneumonia (rare, but consequences of untreated infection would be devastating! • dexamethasone improves survival in S. pneumo meningitis! • ampicillin will cover for listeria in older patients! • COULD ALSO CONSIDER acyclovir if patient has signs of encephalopathy, as HSV encephalitis is treatable! viral meningitis: supportive care! ! SSTI/CELLULITIS: ! presentation: erythema, edema, pain, +/- fever! ! etiology: usually streptococcal, although staph is also common skin flora. In special circumstances (e.g. diabetes) can also be gram negative rods (Pseudomonas)! ! diagnosis: physical exam, CBC. Consider obtaining XR of affected extremity if you have a consideration of necrotizing fasciitis (bacteria and air in the fascial plane) as this is a surgical emergency. ! NOTE wound cultures are only useful to determine presence of MRSA. Otherwise, likely polymicrobial and will reflect skin flora.! ! treatment: ! for MSSA/strep: IV: cefazolin or nafcillin. PO: cephalexin or dicloxacillin! for MRSA: IV: vancomycin. PO: bactrim, doxycycline/minocycline, clindamycin! for necr fasciitis: STAT surgical consult! ! NOTE with newer depot-formulation antimicrobials (dalbavancin, oritavancin) management of SSTI will change substantially in the next few years!! PNEUMONIA:! presentation: fever, cough, purulent sputum, hypoxia, infiltrate on CXR! ! Note: community acquired PNA (CAP) is a distinct clinical entity from health care associated PNA (HCAP). PNA is defined as HCAP if a patient has been admitted to an acute care hospital or in contact with health care facility (dialysis, SNF) within the last 90 days.! ! etiology: ! CAP: S. pneumoniae, Mycoplasma spp., viral; less likely Legionella! HCAP: S. pneumo, S. aureus, GNR (Klebsiella spp., P. aeruginosa, etc.), Legionella! ! diagnosis: CXR, BCx, SpCx, urine legionella antigen (only picks up serotype 1), S. pneumo urine antigen! ! treatment:! outpatient: azithromycin monotherapy or respiratory fluoroquinolone; length of treatment until afebrile x3d! inpatient CAP: CTX 1g q24h + azithromycin 500mg x1 (then 250mg x5d)! inpatient HCAP: vancomycin 1-1.5g q12h + pipercillin/tazobactam 4.5g q6h +/- azithromycin (if patient had been outpatient and has high risk Legionella infection). Consider aztreonam or carbapenem if patient has PCN allergy.! If PCN allergy is anaphylaxis, don't use carbapenem due to 2-5% cross reactivity. 087 UTI/PYELONEPHRITIS:! presentation: fevers, dysuria, urinary frequency, AMS (in elderly). + CVA tenderness, abd pain, flank pain in pyelonephritis.! ! etiology: ! typically Enterobactereciae incl. E. coli, Klebsiella spp., S. saprophyticus! note that in patients with chronic foley, anything goes!! pyelo most commonly ascending in nature! ! diagnosis: UA (WBC elevated WITHOUT significant elevation in squamous epithelial cells, as this indicates unclean catch), UCx, BCx, renal u/s if concern for hydronephrosis, CT a/p if concern for complicated pyeloneophritis, renal capsular abscess! ! treatment: ! uncomplicated UTI (female): Bactrim x3d or ciprofloxacin x3d (note our institution’s E. coli has a lot of cipro resistance) or nitrofurantoin x5d! complicated UTI (male/female): therapy targeted towards etiologic agent, 10-14d course! pyelonephritis: amoxicillin/clav or ciprofloxacin targeted towards etiologic agent, 14d course! asymptomatic bacteriuria: DO NOT TREAT! INTRAABDOMINAL (DIVERTICULITIS, PERFORATED VISCERA):! presentation: abdominal pain, +/- rebound/guarding, fevers! ! etiology: Enterobactereciae (E. coli most common), anaerobes e.g. B. fragilis! ! diagnosis: CT a/p with contrast, consider abd u/s for appendicitis depending on clinical presentation! ! treatment: typically pip/tazo at least initially (good GNR coverage as well as covering B. fragilis). Can narrow ABx depending on culture data. BEWARE giving just cipro/metronidazole given our antibiogram.! ! ENDOCARDITIS:! presentation: may present either acutely or subacutely. Acute: fever, new valvular insufficiency (new murmur, fluid overload), embolic disease. Subacute: B symptoms! ! etiology: ! diagnosis: 2 sets of blood cultures should be taken from SEPARATE sites e.g. one from each arm. Ideal to also have temporally separated blood cultures (30 min apart) but this is not usually feasible in clinical practice.! ! In addition to BCx, patient should have CXR (to assess for septic emboli), EKG (evaluate for structural disease and make special note of the PR interval, which can prolong with valve root abscess), TTE (if negative TEE should be pursued. ! ! Duke criteria are used to determine diagnosis:! • Definite diagnosis is made with either 2 major criteria met, OR 1 major and 3 minor criteria met, OR 5 minor criteria met, OR + culture obtained pathologically from endocardial mass.! 088 • Endocarditis is possible if either 1 major and 1 minor criteria are met OR if 3 minor criteria are met.! ! MAJOR CRITERIA MINOR CRITERIA + blood culture from typical organism (viridans Strep, S. aureus, S. bovis, HACEK, Enterococcus) in 2 separate cultures OR + culture for atypical organism with 2 separate cultures 12 hours apart OR + Coxiella IgG/culture predisposing factor (known cardiac structural disease, known IVDU) evidence of endocardial involvement on echocardiography fever > 38°C evidence of embolus e.g. arterial emboli, pulmonary septic emboli, Janeway lesions, conjunctival hemorrhage immunological problems e.g. glomerulonephritis, Osler’s nodes, Roth spots, +RF ! microbiologic evidence (e.g. single + culture or atypical infection) that does not meet major criteria treatment:! native valve: treatment tailored to etiologic agent. For MSSA/Strep viridans, typically patient will be placed on Blactam (nafcillin or cefazolin). Gentamicin is used for synergy with enterococcal endocarditis and in tricuspid valve endocarditis. CTX often used for GN endocarditis.! prosthetic valve: vancomycin or nafcillin (depending on whether organism is MR or MS). Gent added for synergy.! ! Surgical c/s should be obtained early if patient has evidence of severe heart failure, evidence of septic emboli (to the chest or brain), valve root abscess, S. aureus infection in prosthetic valve. ! ! C. DIFFICILE COLITIS:! presentation: fevers, abdominal pain, diffuse diarrhea (especially if past exposure to antibiotics)! ! etiology: C. difficile… obviously. Antibiotics kill normal gut flora and leave C. diff to repopulate the bowel. Most common antibiotics to cause CDI: #1 cephalosporins, #2 fluoroquinolones, #3 clindamycin.! ! diagnosis: C. difficile PCR. Samples can be tested once weekly; if the patient has had a negative test within the last 7 days, new sample will be rejected unless you make a compelling case to the lab. Consider getting KUB to assess for megacolon.! ! treatment: Metronidazole 500mg tid is agent of choice for first case and for first relapse. PO vancomycin* 125mg-250mg q6h is agent of choice for “severe” CDI (hypoalbuminemia, WBC > 15K, abdominal distention). Could consider fidaxomycin or fecal transplant for refractory disease.! ! 089 *DO NOT use IV vancomycin in the treatment of C. difficile. IV formulation does not penetrate into the bowel.! ! ANTIBIOTICS! ! 090 Cefepime doesn't cover anaerobes. ! ! 091 ! Antibiotics that cover MRSA:! 1. vancomycin! +: commonly used -: renally dosed, bacteriostatic, “vanc creep” ✓: CBC, RFP! 2. daptomycin! +: once daily dosing -: inactivated by lung surfactant ✓: CK (rhabdo), CBC, RFP! 3. ceftaroline! +: broad spectrum (basically CTX + MRSA) -: ID only ✓: CBC (cytopenias after prolonged use)! 4. tigecycline! +: uncommonly used, will cover resistant GNRs also -: does not cover “3Ps” - Pseudomonas, Proteus, Providentia, no urine coverage, low blood concentrations ✓: CBC, RFP! 5. linezolid (+ tedizolid)! +: IV and PO, easy dosing -: bacteriostatic ✓: CBC (cytopenias after prolonged use >7d)! 6. TMP/SMX! +: PO -: ✓: (G6PD)! 7. doxycycline/minocycline! +: PO -: photosensitivity ✓: -! 8. clindamycin! +: PO -: tastes bad, evolving resistance ✓: -! ! ! ! HIV ISSUES! ! AIDS is defined as HIV+ status with either CD4 < 200 OR HIV+ status with an AIDS-defining illness. ! Common AIDS-defining illnesses include:! • invasive candidiasis! • disseminated cryptococcosis! • Kaposi’s sarcoma! • Burkitt’s lymphoma! • invasive cervical cancer! • Pneumocystis pneumonia! • disseminated mycobacterial infection! • Toxoplasma encephalitis! • HIV wasting syndrome! ! The recommendation at this time regarding HAART in patients who are HIV+ is that all patients should be offered antiretroviral therapy. The recommendation is strongest for patients who have a CD4 count of < 350. Patients with exceedingly high viral load or those who are pregnant should be started on HAART more urgently.! ! Before starting HAART, it should be confirmed that patient does not have any opportunistic infection. Once patient’s immune status improves, they are at risk of Immune Reconstitution Inflammatory Syndrome (IRIS), in which their now restored immune system vigorously attacks an infection which had previously gone unnoticed. If patient has an underlying OI, that should usually be treated before HAART is initiated.! ! 092 When presenting a patient with HIV disease, you should know current CD4 and viral load, nadir of CD4, whether they have had any opportunistic infections, and current antiretroviral regimen.! ! Also, when you admit a patient to Carpenter with HIV disease, you should contact the SIU (Special Immunology Unit) to obtain the patient’s face sheet. This sheet discusses the patient’s primary care history, history of HAART, any OIs, all CD4/VL data, etc.! ! ANTIRETROVIRALS! ! All currently used combinations of antiretrovirals are in combination to block the development of resistance. ! ! Types of antiretroviral agents:! NRTI (nucleoside reverse transcriptase inhibitor): essentially a “fake” nucleoside base; when it is integrated via reverse transcriptase enzyme, DNA synthesis stops as there is no moiety to hook another base to. Thus HIV DNA is not created from RNA, decreasing viral load.! NNRTI (non-nucleoside reverse transcriptase inhibitor): agents that bind directly to the active site of the RT enzyme, thus not allowing creation of HIV DNA. ! PI (protease inhibitor): agents that bind to viral proteases, thus blocking creation of infectious virions! INSTI (integrase strand transfer inhibitor): blocks integrase enzyme, which is required for entry of viral DNA into human cell! entry inhibitor: blocks formation of gp120 complex which allows entry of HIV into the cell. NOTE maraviroc, the only example in this class, only works in patients who have CCR5 coreceptor, so tropism testing must be completed prior to initiation of this agent! ! The optimal antiretroviral therapy for a treatment-naive patient consists of 2 NRTIs and a third “other” drug from one of the other 3 classes.! ! Common regimens include:! • efaverenz (NNRTI) / tenofovir (NRTI) / emtricitabine (NRTI)!aka Truvada • atazanavir (PI) / ritonavir (booster for PI) / tenofovir / emtricitabine! • darunavir (PI) / ritonavir / tenofovir / emtricitabine! • dolutegravir (INSTI) / tenofovir / emtricitabine! ! As patients’ virus becomes more resistant, patients may require more complex regimens. ! ! ! ! ! ! ! ! ! ! ! ! ! ! 093 PRIMARY PROPHYLAXIS FOR PATIENTS WITH HIV DISEASE! ! ORGANISM PROPHYLAX AT WITH (PREFERRED) OR UNTIL PCP (PneumoCystis Pneumonia) CD4 < 200 OR history of oropharyngeal candidiasis Bactrim 1 DS daily (could consider Bactrim 1 DS MWF) dapsone, atovaquone, inhaled pentamidine CD4 > 200 for 3 months Toxoplasmosis CD4 < 100 (if Toxoplasma IgG+) Bactrim 1 DS daily (could consider Bactrim 1 DS MWF) dapsone/ pyrimethamine + leukovorin CD4 > 200 for 3 months M. avium complex CD4 < 50 azithromycin 1200mg weekly clarithromycin weekly, rifabutin CD4 > 100 for 3 months Histoplasmosis CD4 < 150 if high exposure risk or living in hyperendemic area itraconazole 200mg daily - CD4 > 150 for 6 months Primary prophylaxis is not warranted for cryptococcal infection given lack of survival benefit. Primary prophylaxis is not warranted for CMV given cost and lack of survival benefit.! ! All HIV + patients should also maintain UTD vaccinations.! ! ! ! 094 UHCMC Adult Patients Beta-lactams 8 8 8 8 4 4 2 4 4 16 1 2 4 Tetracycline 32 Nitrofurantoin 2 Trimethoprimsulfamethoxazole Quinolones 8 Levofloxacin Aminoglycosides 8 Ciprofloxacin Agents predominantly used for urinary tract infections 8 Amikacin Carbapenems 16 Tobramycin Monobactam 8 Gentamicin Cephalosporins 8 Ertapenem Penicillins University Hospitals Case Medical Center Antimicrobial Susceptibility of Gram-Negative Bacilli 2014 Susceptible breakpoint (ug/ml) Meropenem Escherichia coli Enterobacter cloacae Enterobacter aerogenes Citrobacter koseri Citrobacter freundii Acinetobacter baumanii 195 5707 283 142 118 173 95 6 55 1 10 Proteus mirabilis Morganella morganii 652 519 84 - 84 4 4 5 Klebsiella oxytoca 1421 Pseudomonas aeruginosa 119 3 Serratia marcescens 149 - 0 Stenotrophomonas maltophilia 85 88 89 7 98 - 86 97 86 100 87 47 87 4 9 98 8 7 84 80 91 -* -* 83 -* 86 90 94 94 -* -* 100 -* 92 90 89 94 -* -* 100 -* 88 90 93 94 -* -* 100 -* 37 95 90 94 95 93 96 100 97 38 88 89 88 94 74 89 99 85 - 99 96 100 100 98 97 100 98 38 100 96 100 100 98 97 100 97 41 99 96 100 100 99 98 100 97 - 91 94 96 92 97 99 97 96 44 91 91 97 92 97 98 100 94 53 100 97 100 100 100 99 100 100 51 69 88 92 80 94 97 99 91 38 75 90 94 81 96 97 99 94 40 45 82 88 78 85 91 98 84 39 0 47 87 97 25 21 65 99 - 96 - 99 - 99 - 99 91 99 90 99 77 94 88 100 89 100 - 100 80 95 94 95 95 100 76 82 75 87 1 80 90 92 5 99 - - 0 - -* - -* - -* 39 -* - 98 - 85 - 98 - 99 - 99 - 97 11 90 21 98 26 93 88 98 - 10 - 94 69 - - - - 1 98 Percentage of strains inhibited at susceptible breakpoint Imipenem Klebsiella pneumoniae No. tested Aztreonam 87 94 - 86 74 86 91 78 85 99 99 84 - Cefepime - Ceftazidime - Ceftriaxone - Cefotaxime - Cefuroxime 39 Cefazolin - Pipercillintazobactam - Amoxicillinclavulanate *Resistance to second and third generation cephalosporins may develop during therapy with these agents 095 Ampicillin 0.1 / 8 UHCMC Adult Patients Macrolides Aminoglycosides Quinolones Agents predominantly used for urinary tract infections 99 32 92 4 96 2 79 99 1 67 59 82 2 60 48 - 58 1 - 47 72 99 - 97 - 66 10 24 4 60 72 8 100 100 - 82 - - - 0.5 2/4 37 - 51 0.5 2 100 75 15 4 0.5/1 100 47 - 4 2 100 78 d c 58 60 85/94g Percentage of strains inhibited at susceptible breakpoint - 33 Beta-lactams University Hospitals Case Medical Center Antimicrobial Susceptibility of Gram Positives 2014 Susceptible breakpoint (ug/ml) No. tested - 99 12 100 12 100 3139 46 Staphylococcus aureus - - - - 12 - 12 21 1073 100 Coagulase neg staphylococci 100 99 82 - 97 1090 100 10 - 11 - Enterococcus faecalise 207 53/92f 3 Enterococcus faeciume - 99 Nitrofurantoin 93 Tetracycline 27 Trimethoprimsulfamethoxazole - Moxifloxacin - Levofloxacin - Ciprofloxacin 74 Gentamicin Synergyb - Gentamicin Vancomycin - Clindamycin Oxacillin a 100 Erythromycin Ceftriaxone - Linezolid Amoxicillin 72 Streptococcus pneumoniae Daptomycin Penicillin G Susceptibility at meningitis (<0.5 ug/mL)/non-meningitis (<1 ug/mL) breakpoints Susceptibility at meningitis (< 0.06 ug/mL) and non-meningitis (< 2 ug/mL) breakpoints Enterococcus species are intrinsically resistant to cephalosporins, macrolides and trimethoprim-sulfamethoxazole. Staphylococcus aureus /other Gram-positive breakpoints Staphylococcus aureus/Enterococcus breakpoints For penicillin- and vancomycin-susceptible strains, synergy can be achieved with gentamicin provided strains do not have high-level gentamicin-resistance. a Staphylococci that are oxacillin resistant are resistant to all b-lactam agents, including penicillins, b-lactam/b-lactamase inhibitor combinations, carbapenems and cephalosporins with the exception of ceftaroline b c d e f g 096 Ampicillin Gastroenterology/Dworken Gastrointestinal Bleeding 1.Key Historical Elements 1. Upper vs. lower GI bleeding – Upper (Epigastric pain, N/V, hematemesis, coffee ground emesis, melena) vs. Lower (hematochezia, bright red blood per rectum, diarrhea) *Exceptions to rule: If unstable, hematochezia may sign of brisk UGIB. Melena can also be from LGIB (distal small bowel, R sided colonic). 2.General historical elements- duration, # of episodes, prior GIB, asp/NSAID/plavix/Coumadin use, alcohol use, s/s of hypovolemia 3.Focused history to determine etiology (e.g. PUD (NSAID/alc use/H.pylori), Mallory-Weiss (retching, vomiting prior to hematemesis), diverticular (painless hematochezia), etc. 4. Prior endoscopy? Obtain reports! 5.Rule out oropharyngeal source of bleeding or epistaxis 2. Key Exam Findings1. Vitals- Assess degree of hypovolemia (tachycardia, blood pressure, orthostatics). 2.Perform your own rectal (assess for hemorrhoids, anal fissures, color of stool) 3.Labs 1.STAT CBC (compare H/H to baseline), RFP (BUN/Cr in 30s suggests UGIB), LFTs, coags, type/screen. Note: H/H may be normal or only slightly decreased in first 24h prior to equilibration). 4.Management 1. Stabilize/resuscitate- Keep NPO, place 2 large bore IVs (18 gauge), start IVF (typically NS, if hypotensive or orthostatic, bolus 1L (or 250-500cc if HF or ESRD), repeat until vitals normalize then place on maintenance IVF *If remains unstable despite IVF MICU. 2.Transfuse- Hgb goal around 7 for UGIB, may shoot for >8 in CAD. Transfuse as needed (1 unit pRBC should increase Hgb by 1). Consider higher transfusion goal in patients with CAD. O-neg if emergent. Monitor H/H q6-q8h until stable. 3.Reverse coagulopathy1. If INR elevated, give FFP (typically 2-4 units initially) and/or Vitamin K as needed (Vit K more effective in Coumadin patients than cirrhosis) 2. Hold NSAIDs, antiplatelet, anticoagulation if possible. Exceptions exist however (recent cardiac stents, mechanical heart valves, etc and will need individual consideration of risk/benefits). . 4.NG lavage – Controversial, unclear overall clinical benefit, misses 18% of UGIB 5.Medications: 1. Acid suppression- If suspect actively bleeding peptic ulcer, STAT PPI 80mg IV x1 followed by PPI drip at 8mg/hr. In other cases of acute UGIB, can use PPI IV 40mg BID. 2. Cirrhotic patients 1. Suspected variceal bleeding: Octreotide 50 ug IV x1 then 50ug/h, PPI drip as above, and antibiotics (see below) 097 2.Antibiotics –Start Ceftriaxone IV (or other abx prophyaxis) in all cirrhotic patients with GI bleeding (decreases infectious complications) 4.Consult GI – If patient stable, no need for emergent GI consultation overnight. If unstable, transfer to MICU and GI may perform emergent endoscopy in the unit. Parameters for endoscopy: INR <1.5 and platelets >50k. Give add’l FFP or platelets as needed in preparation Approach to cirrhotic patients 1. Important background information for each patient 1.Etiology of cirrhosis (e.g. 2/2 alcohol, viral hepatitis, autoimmune, metabolic, NAFLD, etc) 2.Child Pugh Class (find criteria online), MELD score (calculator online) 3. Known complications from cirrhosis (1. Ascites (?on diuretics, ?requires LVP), 2. History of spontaneous bacterial peritonitis (SBP) (?on antibiotics for SBP prophylaxis), 3. History of gastroesophageal varices (grade, date of last EGD, ?on nonselective beta blockade if applicable, ?prior band ligation) 4. History of hepatic encephalopathy (HSE) (?on lactulose and/or rifaximin), 5. History of hepatorenal syndrome 5. General information (Hepatologist information, date of last HCC screening, date of last EGD (varices screening), ?currently being evaluated for transplant) 2.Compensated or decompensated? 1. Signs for decompensated cirrhosis include hepatic encephalopathy, ascites, jaundice, GI/variceal bleeding 2. If decompensated, must evaluate possible inciting factors (details below). 2.Common problems encountered in cirrhotic patients 1. Ascites 1. Typically treated with salt restriction and combination of lasix and spironolactone (typically 40mg and 100mg daiy or equal proportions of this). 2.Refractory ascites (either diuretic resistant or diuretic intolerant (AKI, hyponatremia, potassium abnormalities with diuretics). 3. If admitting cirrhotic patient with gross signs of volume overload (worsening LE edema, ascites) 1. Evaluate reason for decompensation (compliance with sodium restriction, medication compliance, signs for infection (blood culture x2, u/a, ucx, CXR, diagnostic paracentesis to rule out SBP). 2. Start/continue/increase diuretic regimen of lasix and spironolactone and uptitrate as renal function and sodium tolerate. 3. If diuretic resistant or intolerant, may require large volume paracentesis (LVP) 2. Spontaneous bacterial peritonitis 1. Presentation: Abdominal pain, fevers, chills, encephalopathy but can be asymptomatic as well 2. Must rule out SBP in cirrhotic patients with ascites that present with abdominal pain, fever, s/s infection, hepatic encephalopathy. 098 *No one will ever fault you for performing a diagnostic paracentesis to rule out SBP but they certainly will if you don’t when it is indicated. Ask a senior to assist you with this. 3. Diagnosis – ascitic neutrophil count of >250cells/uL. Ensure to send ascitic fluid for gram stain, culture in addition to cell count and differential when performing dx paracentesis as well as blood cultures x2, etc for infectious workup. 4. Treatment of SBP – 1. Ceftriaxone IV + IV albumin 1.5g/kg at time of diagnosis and 1g/kg on day 3. If clinically not improving, repeat paracentesis on day 3 to assess for appropriate decrease in ascitic neutrophic count (success = >25-50% decrease). 5. SBP prophylaxis needed if history of SBP or if ascitic fluid total protein <1. Can use Cipro, norfloxacin, bactrim. 3. Hepatic Encephalopathy 1. Diagnosis- It is a clinical diagnosis of encephalopathy + asterixis. Do not check ammonia as it has poor sensitivity and no role in diagnosis. 2.Evaluation- Evaluate for possible precipitants: 1. Medication compliance (check with family members if patient was taking lactulose and/or rifaximin and how many BMs they were having each day (need 2-3 BMs ideally) 2. GI bleeding 3.Infection – Check blood cultures x2, urinalysis, urine culture, CXR, sputum culture, perform diagnostic paracentesis to rule out SBP (very important) 4. Offending substances/medications – Most commonly alcohol, drug use, narcotics, benzodiazepines. 5. Azotemia – Follow up renal function panel for BUN and Cr 6. Hypoxia, hypo/hypervolemia, hypo/hyperkalemia 3. Treatment 1. Treat underlying precipitants (e.g. treat SBP if present, hold offending medications like narcotics/benzos, etc). 2. Start lactulose and titrate to 3-4 bowel movements per day (may start q2h until first BM, then QID or more PRN). May had rifxaimin 550mg PO BID if needed. If obtunded, NG or rectal. 3. Will need to discharge on lactulose +/- rifaximin for secondary prevention 4. GI bleeding 1. Evaluation of GI bleeding as per GI bleeding section 2. *Take extra caution in cirrhotic patients with acute upper GI bleeds. Variceal bleeding is a serious complication which patients can decompensate suddenly and severely from. Thus, patients with suspected variceal bleeding are often monitored/managed in the MICU. Prior to transfer, please ensure they have good IV access, are on adequate IV fluids, PPI drip, octreotide drip, antibiotics for SBP prophylaxis as above and ensure GI is aware. 099 3. Patients with variceal bleeding or medium to large varices on variceal screening will need to be on nonselective beta blockers, titrated to HR. They also may need esophageal band ligation in future. 5. Acute kidney injury 1. Evaluation - Evaluate AKI in cirrhotic patients as you would in any other patient (evaluate volume status, NSAID use, recent contrast exposure, check u/a, ucx, urine electrolytes, renal ultrasound, etc). 2. Management – Hold diuretics, trial of volume expansion with albumin 3. Hepatorenal syndrome is on the differential but other etiologies for acute kidney injury are usually the culprit so evaluate common causes first 6. General tips: 1. Tylenol is not absolutely contraindicated in patients with cirrhosis. In non-alcoholic patients, can use up to 2g/day. However, would avoid in alcoholic patients. 2. Avoid narcotics, benzodiazepines, sleeping aides (ambien, benadryl) as not to precipitate HSE. 3. Avoid NSAIDs. Approach to elevated LFTs: Assess the pattern of liver injury a. 1. Hepatocellular: Mainly elevations in ALT and AST i. 1. Degree of elevation is important. 1. AST, ALT >1000s severe viral hepatitis, drug induced liver injury, ischemia, Wilson’s, autoimmune hepatitis 2. Workup: a. 1. Viral hepatitis workup (Acute hepatitis panel +/- CMV, EBV, HSV, VZV) b. 2.Autoimmune hepatitis workup: ANA, anti smooth muscle antibody (ASMA), anti-liver kidney antibody (anti-LKM) c. 3.Wilson’s workup: ceruloplasmin d. 4.Vascular etiologies: RUQ ultrasound with Doppler e. 5.Drug workup: Tox screen, alcohol, tylenol level ii. 2. Clues: 1. AST/ALT >2:1 suggests alcoholic hepatitis, cirrhosis b. 2. Cholestatic: Elevated alk phos and bilirubin +/- aminotransferases i. 1. First step: determine if ductal dilation is present (RUQ u/s or CT) 1. Ductal dilation present suggests biliary obstructiona. 1. DDx includes choledocholithiasis, pancreatic cancer, sclerosing cholangitis, cholangiocarcinoma 2. No ductal dilation: a. 1. DDx is decompensated cirrhosis, hepatitis, medication induced, sepsis c. 3. Isolated hyperbilirubinemia: Elevated bilirubin, normal alk phos and aminotransferase i. 1. Conjugated hyperbilirubinemia Check RUQ u/s ii. 2.Unconjugated hyperbilirubinemia Assess for hemolysis (peripheral smear, LDH, haptoglobin) Approach to nausea /vomiting 100 1. Approach – best to describe by chronicity and presence of abdominal pain a. 1. Acute or chronic?. Abdominal pain?, b. 2. Vomiting of undigested food eaten hours earlier? (suggests gastric obstruction or gastroparesis) c. 3. Abdominal distension or feculent vomitus? (suggests obstruction of small intestine) d. 4. Abd pain history (radiates to back, increases with PO intake? (pancreatitis vs. biliary colic) e. 5. Recent changes in medications, motion sickness, new/bad foods, diarrhea? (infectious gastroenteritis, food poisoning), hx GIB? (UGIB can cause N/V), recent surgeries (postop ileus) 2. Etiologies of acute N/V a. 1. Acute onset with severe abdominal pain serious illness potentially with surgical intervention. EXCLUDE SURGICAL DISORDERS. i. 1. GI obstruction (acute abd series/KUB, CT) ii. 2. Mesenteric ischemia (CT/CT angiography) iii. 3. Pancreatitis (lipase +/- CT) iv. 4. Biliary colic (CT, RUQ u/s) v. 5. Conditions cause peritonitis (e.g. appendicitis or perforated viscus) (CT) vi. 6. Cardiac – acute ischemia b. 2. Acute onset of N/V without abdominal pain DDx: Medications, Motion sickness, food poisoning, infectious gastroenteritis, hepatitis, upper GI bleeding, postoperative ileus, acute CNS disease 3. Etiologies of chronic or recurrent N/V a. 1. Chronic with abdominal pain i. 1. GI disorders that result in partial or intermittent obstruction of stomach or small intestine b. 2. Chronic N/V without abdominal pain i. 1. Disorders that impair gastric emptying or small intestine motility ii. 2. Non-GI causes: Medications, pregnancy, intracerebral disorders, cardiac disease, endocrine disease, labryrinth disorders, psychiatric disease (bulimia), functional disorders 4. Diagnosis (review meds, CBC/RFP/LFTs/lipase/amylase/GGT/imaging +/additional studies including acute abd series (upright), CT, EGD/enterography, GI motility (emptying), head CT/MRI 1. Acute without abdominal pain - Most cases of acute vomiting without abdominal pain are self limited and require no evaluation a. 1. Medication related sx and pregnancy should be excluded b. 2. Severe vomiting – obtain serum electrolytes c. 3. Hyperglycemia may cause acute gastroparesis d. 4. Increased liver chemistries or pancreatitc enzymes suggest hepatobiliary or pancreatic disease 2. Acute N/V with abdominal pain – 101 a. 1. Obtain abdominal plain radiographs or CT – look for GI obstruction, perforated viscus, pancreaticobiliary disease 3. Chronic N/V of uncertain cause – distinguish structural GI disorders, GI motility disorders, and non-GI disorders a. 1. EGD, enterography, abdominal cross sectional imaging, GI motility studies, head CT/MRI may be indicated 5. Treatment a. Address underlying cause, treat symptomatically with anti-emetics Approach to a patient with inflammatory bowel disease 1.Characterize the IBD 1.Ulcerative colitis (classify by location: proctitis, L sided, or pancolitis) 2.Crohn’s disease (comment on prior complications: 1.Perianal disease (fissures/fistulas/perirectal abscess), 2. stricturing disease, 3. fistulas (perianal, enteroenteric, rectovaginal, enterovesicular, enterocutaneous), 4. Abscess, 5. Malabsorption (resulting in gallstones, calcium oxalate kidney stones, vit D deficiency) 3.Prior treatment history (e.g. UC: mesalamine, 6 mercaptopurine/azathioprine; CD: 6MP/AZA, anti-TNF alpha, MTX). Why prior treatments failed (unsuccessful vs. inability to tolerate, etc). 4.Prior imaging and endoscopy 2.History 1.Abd pain, N/V, fevers, hematochezia, # of BMs (diarrhea vs. constipation/obstipation) 2.Severity of flare- # BMs/day, systemic toxicity symptoms, ?tolerating PO, weight loss, obstructive symptoms 3.Extracolonic symptoms- rashes, ulcers, eye pain, CP, joint pains 3.Management of acute flare 1.Labs – CBC, RFP, LFTs, ESR/CRP, stool studies (C diff, stool culture, fecal leukocytes), +/- evaluation for vitamin deficiencies in Crohn’s (Fe, B12, folate if anemic; consider vit D) 2.Imaging – consider CT A/P initially. May need MR or CT enterography in CD patients to further evaluate disease 3.Rule out infection (stool studies) before treating with immunosuppressants and/or biologics 4.Acute flare treatment (goal to reduce remission quickly): Depends on severity of flare but typically use steroids (PO 40mg prednisone if moderate, IV steroids if severe). Unless systemic signs for infection, typically do not need antibiotics; exception is perianal disease in Crohn’s disease (Cipro/Flagyl or Augmentin). Pain control, NPO until patient improves. 1.If fails steroids, may require infliximab, etc (always check PPD, hep B/C prior to starting) 5.Assess for complications: 1.UC – Toxic megacolon (Dx with KUB, colon dilation >6cm on KUB, systemic toxicity, risk of perforation, tx with IV steroids and broad spectrum antibiotics, surgery if fails to improve 48-72h 102 2.CD – 1. Abscess (perianal - abx, call colorectal for possible I/D, abd abscess-tender abd mass, SIRS criteria), 2. Stricture (constipation/obstipation, can lead to SBO), 3. Fistulas 6.Consider endoscopic evaluation to restage disease or to further evaluate Approach to acute pancreatitis 1.Sx: Epigastric pain, N/V, radiation to back, assoc with food (often fatty) intake 2.Diagnosis: Elevated lipase (more specific than amylase; can have false + in renal failure, DKA), CT A/P (helps but not required for dx) 3.Evaluate etiology: Most commonly 2/2 alcohol and gallstones (make up >70% of cases), but assess for offending medications, hx malignancy (obstructive), metabolic (hypertriglyceridemia, hypercalcemia), recent ERCP, trauma, family hx pancreatitis, autoimmune pancreatitis 4.Tx: 1. Supportive 1. IVF (careful in systolic heart failure or ESRD patients) 2. Pain control (typically need IV, then transition to PO). 2.Assess for complications: 1.Organ failure – renal, respiratory failure, shock (higher mortality) 2.Acute fluid collection- common, no treatment needed 3.Pseudocyst- no tx needed acutely as most resolve spontaneously, if sx persists 4-6 weeks or if large (>6cm), need drainage (usually via cystgastrostomy (GI) but IR (percutaneous) or surgical drainage also sometimes considered) 4.Sterile pancreatic necrosis- supportive care, use of empiric antibiotics (theoretically to prevent converstion to infected necrosis) is controversial and not routinely used; however may be reasonable if SIRS criteria/signs for infection/hemodynamic instability are present. 5.Infected pancreatic necrosis: Carbopenems are usually abx of choice. Usually no intervention needed in acute setting (allow for organization of necrosis). 6.Pancreatic abscess- Abx and CT guided drainage 7.Ascites or pleural effusion: 2/2 disrupted pancreatic duct, may require ERCP and pancreatic duct stenting 103 HBsAg Neg Anti-HBc Total Neg Neg Anti-HBc IgM Positive Neg Anti-HBs Vaccinated Never exposed What it means HBV Serology Interpretation Neg Neg Acute HBV Neg Neg Chronic HBV Positive Positive Neg Neg Positive Neg Neg Positive Positive Positive Neg Neg Positive Positive Immunity (past infection) Neg “Isolated Core” *variable etiology 104 Endocrine DKA -Predominantly with failure to produce insulin rather than with insulin resistance (this is why type 1 diabetics are much more prone to DKA) Diagnosis-Look for type 1 DM with AMS, dehydration, nausea/vomiting. Often have glucose in 400-600 range with AGMA (glucose can be even lower in some cases). Send serum ketones (‘beta hydroxybutyrate serum’ or “ketones serum’ at UH). Pts often have AKI 2/2 dehydration. Etiology- Rule out the presence of a 2nd issue that needs addressed. MI, infection, alcohol or drug intoxication, new steroid use, type 1 DM with missed insulin. Get CBC, RFP, phos, mg, LFT, lipase, lactate, ABG, EKG and utox, consider CXR/UA. Anion gap is Na-(Cl + Bicarb). Most don’t use potassium anymore, those who do just change their ‘normal’ range. Since when discussing a gap most assume you didn’t use potassium it’s easiest just to avoid. Tips: 1) Albumin drives the gap (it’s a negatively charged protein). If albumin is low, your ‘normal’ gap should decrease 3 for each g/dL decline in albumin. If albumin is 3, expect a gap of 9 rather than 12. 2) Don’t correct the sodium for hyperglycemia when calculating the gap (this will erroneously show most severely hyperglycemic patients with AGMA). Glucose draws water into the serum, diluting both sodium and bicab/chloride levels. As glucose goes down, the water goes back into the cells and Na/Cl/bicarb all rise. HHS -Very high sugars (>600) in patients with no ketoacidosis. Serum osmolarity elevated (often >350). -Often have AMS, usually DM2. -REMEMBER, glucose is a great diuretic. These patients are often profoundly dehydrated (that’s why they’re hyperosmolar). 2L bolused is a start. Most will need 3 or more liters in their first 3-4 hours. Unless severe HF or ESRD, don’t under-resuscitate these patients. Fluids are the gold standard and bring down glucose some on their own. - ICU versus floor: Unlike DKA, these patients can often be managed on the floor with initial fluid bolus and 10U IV push regular insulin in the ED/UCC, then subcu short acting based upon that response on the floor (adding long acting once you have an idea of their needs). If hemodynamically unstable, very high serum osm, or the sugars just aren’t responding to your insulin, consider ICU and gtt (active insulin drips are not safe on the floor at either UH or the VA). Keep the fluids going and bring the sugars down gradually. Replete electrolytes. -As with DKA, ensure there is no other cause of HHS (MI, infection…). Blaming a patient who missed insulin is common, but sometimes it’s not the real cause. 105 ± # Mild hypotension or normal (Euvolemia) # ± Start IV fluids: 1-2 L of 0.9% NaCl/hr (15-20 mL/kg/hr) x 1 hour INSULIN BOLUS Insulin Regular 0.15 units/kg IV If BG did not fall by 50 mg/dL within the first hour, double the insulin rate hourly until BG falls by 50 mg/dL or BG <250 mg/dL. Continuous Infusion Insulin Regular 0.1 units/kg/hr IV (max:8 units/hr) If BG falls > 50 mg/dL within one hour and BG >250 mg/dL continue insulin at the same rate NO 3.3 - 5 mEq/L > 5 mEq/L POTASSIUM* < 3.3 mEq/L PO4 >1.5 ¶ 15 mmL NaPO4 IV No KCl PO4 >1.5 NO PO4 >1.5 20 mEq KCl lV YES NO YES 40 mEq KCl IV 15 mmL KPO4 IV (20 mEq K) STANDARD LABORATORY ASSESSMENT Plasma glucose Basic metabolic panel (calculated anion gap and effective osmolality) Phosphorous, magnesium Beta-hydroxybutyrate Complete urinalysis with urine ketones by dipstick Arterial blood gas Complete blood count with differential Electrocardiography Capillary glucose Q1h BMP, Phos, mag, Q4h x3 then q6h as long as needed *Potassium (in renal failure patients individualize care) If initial K < 3.3 mEq/L, replete before initiating insulin infusion If potassium levels are critically low additional doses of KCl might be needed Maximum infusion rate: 20 mEq/hr Maximum concentration: PERIPHERAL line = 0.08 mEq/mL (ex: 20 mEq in 250 mL) CENTRAL line = 0.4 mEq/mL (ex: 40 mEq in 100 mL) ¶ Phosphorus (in renal failure patients individualize care) Maximum infusion rate: 7.5 mmol/hr 15 mmL KPO4 IV 20 mEq K) and 20 mEq KCl IV ¶ YES ¶ GUIDELINES FOR THE MANAGEMENT OF ADULT PATIENTS WITH DIABETIC KETOACIDOSIS IV Fluids Hypovolemic shock (administer 0.9% NaCl) Follow the fluid resuscitation guidelines Serum Na Low (start with 200cc/hr NS, adjust for hydration status) Evaluate corrected serum Na (for each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq) Serum Na High or Normal (0.45% NaCl at 4-14 mL/ kg/hr depending on hydration state) Serum glucose reaches 250 mg/dL *Change the fluids to 5%dextrose with 0.45% NaCl at 150-250 mL/hr *Reduce the insulin infusion rate by one half Stop insulin infusion when: *Patient is tolerating at least a full liquid diet *Anion Gap normalizes *Maintenance insulin therapy has been initiated Insulin infusion should be continued for 1-2 hours after SC insulin is administered For dosing insulin use Ideal Body Weight Diabetes Care 27;S94102, 2004. Individualize the treatment of patients with underlying renal failure, and/or heart failure. 106 Diabetes Management in the inpatient (not an exhaustive list, just the high points) Admitting: PO Meds: If they’re on metformin, just hold it initally(it’s difficult to know who will need IV contast, but if patient chilling on floor could restart if planned to d/c on it). NPO patients should not be on sulfonylureas. Other oral hypoglycemic agents should be held in the NPH or sick patients, but can frequently be continued. Insulin: Insulin: Except for patients with low insulin requirements (<25 units/day) generally ~50% of daily insulin should be given as basal (NPH or lantus) and ~50% as short acting. Basal-bolus results in better glycemic control than sliding scale insulin (SSI), but runs a risk of hypoglycemia if you do not actively titrate insulin doses on a daily basis! Always ask patients how much insulin they are taking as the med list is notoriously inaccurate for dosing. Long acting insulin should not be entirely stopped, even in NPO patients. In patients who are likely to eat, CONTINUE mealtime bolus insulin and continue to titrate. If NPO or likely not to eat, HOLD bolus short acting insulin and decrease the long acting to 50-70% of home dose and have SSI (sliding scale insulin) as a correction factor. Patients on 70/30 at home should not be continued on this if they’ll be NPO or eating very little. Short acting insulin should be continued if eating, but make sure to adjust for the amount that patients are eating in hospital. Make sure to specify in order to HOLD if not eating a meal. SSI: The protocols are poor quality, but it’s what we have. At the VA the SSI dosing is easy to change, more difficult at UH. Most dosing will overdose a type 1 diabetic and underdose an insulin resistant long-term type 2 diabetic. Remember always, lows are more dangerous than highs. A call about a patient going to bed with a sugar of 295 is not a huge problem. A call about a patient going to bed with a glucose of 45 is a HUGE problem. Not every diabetic needs a sliding scale, but every diabetic needs the ‘hypoglycemia order set’. For type I diabetics, use the customizable sliding scale with doses specific for their needs. Active management: Often times a patient is not eating well and their long acting is cut in half on admission with addition of sliding scale. This is fine, but each day if the patient is eating roughly the same and blood sugars are above 200, fold ½ of the previous day’s sliding scale use into their long acting, moving it towards their home regimen (if they’re on lantus 10 qhs and used 12 of SSI the day before, try 16 of lantus tonight). Steroids: We all know they increase sugars, often we’re caught chasing sugars with increased insulin. Remember when the steroids stop the sugars drop and the insulin should drop to pre-steroid levels. When in doubt go low on the insulin and let them ride high for a day or two while you get the proper dose figured out. Expect the steroid effect on hyperglycemia to last for at least 24 and max 48 hours after last dose of prednisone/dexamethasone. 107 Discharging: Metformin is the hospitalist’s enemy and the PCP’s friend. Don’t forget to restart the metformin unless there is new renal failure. Decide if anything happened during the stay (poor DM control, new steroids, worsening renal failure…) that should change their home insulin regimen. If not, don’t make dramatic adjustments to their PCP’s regimen. Throw the PCP a bone and order an A1c while they’re in house to give them a head start at the next visit. Always give metformin with meals to minimize GI side effects. Hyperthyroid -Classic sweating, tremor, tachycardia, diarrhea symptoms. If the TSH is low proceed to Total and Free T4 (remember pregnancy and women on contraceptive have increased total T4) -If TSH down but FT4 is normal consider sick euthyroid in our inpatients at UH and the VA. -With low TSH and high FT4, hx, exam, an radioactive iodine uptake scan will usually guide the answer (Graves has diffusely high uptake, subacute thyroiditis often painful, Jod-Basedow associated with iodine or amiodarone, toxic multinodular goiter has multiple nodules on uptake…) -Receiving IV contrast will affect the result of uptake scan-usually avoid in inpatients. -Beta blockers (all help the symptoms, propranolol has the best evidence for also decreasing T4->T3 conversion) -Propylthiouracil, methimazole, radioactive iodine are options based on diagnosis and patient needs. If at this point, talk with endocrine. -Thyroid Storm: hyper-T acutely after sickness or stress. It’s a cause of fever, tachy, hypotension, AMS and is often initially misdiagnosed as sepsis. Tx includes starting with propranolol and PTU, then iodine, and often the addition of steroids. If you think it’s true thryroid storm endocrine should see the patient soon. -In the Unit: remember high dose steroids and dopamine/dobutamine all decrease TSH Hypothyroidism -Symptoms: fatigue, hyporeflexia, wt gain, slow speech. -Myxedema coma involves nonpitting skin thickening and progressive mental status loss. TSH often>100 -Diagnosis: Both at UH and the VA, start with TSH and then get TF4 and FT4 =. In primary (Hashimoto’s, iodine deficiency, surgical) think high TSH and low FT4, though T3 may be normal in iodine deficiency. In secondary (pituitary failure) TSH will also be low. -Treatment: start low (25 or 50mcg) and gradually increase with levothyroxine (watch out for tachycardia and increased cardiac demand in those with heart disease). In myxedema coma you’re too far behind to use oral levothyroxine alone, call endocrine and prepare for IV levothyroxine. Remember: IV levothyroxine is half the PO dose 108 How to conduct a Cosyntropin Stim Test (looking for adrenal insufficiency) 1.No utility in chronic steroid use (axis is suppressed). Stop acute steroids at least 24 hours prior. Decadron is an option which doesn’t interfere with the test. 2. Draw a random early AM cortisol. If it’s more than 12 it’s not adrenal insufficiency unless patient under severe stress. 3. Given parenteral cosyntropin 0.25mg 4. Draw cortisol and ACTH levels at baseline before cosyntropin and cortisol at 30 and 60 minutes after cosyntropin (if 2 sticks is difficult, just get one after 45-60 minutes) -If serum cortisol is over 18, it’s not adrenal insufficiency. The most challenging part is coordinating with nursing. Talk with the RN and find out when a good time for their schedule is, then explain exactly how it needs to be done. 109 Palliative Care 1. Pain management a. Basics i. Perform a complete assessment of the pain. Pain scale 0-10, Functional pain scale 0-5. ii. WHO pain pyramid: Non-pharmacologic pain management -> add non-opioid-> add mild opioid-> add strong opioid-> add interventional pain management iii. WHO 3 step model: Step 1 mild pain= Aspirin, Acetaminophen, NSAIDs, + Adjuvants, Step 2 moderate pain= ASA/Acet + codeine/ hydrocodone/ oxycodone, Tramadol, low-dose oxycodone, + Adjuvants, Step 3 severe pain= Morphine, Oxycodone, Dilaudid, Fentanyl, + Nonopioid analgesics, + Adjuvants iv. Always start a bowel regimen if opiates are initiated* v. Manage side effects vi. Re-assess and adjust as necessary, always add hold for sedation when ordering opiates. vii. Call Palliative Care for help/advice x35614. They’re always happy to help. b. Opioid Conversions: i. Starting long acting opiate (for morphine and oxycodone): Add total doses of breakthrough opiate given in 24h and divide into 2 (q12h) or 3 (q8h), given as an extended release formulation. ii. Rescue dose: 10% of total daily (24h) dose given as an immediate release formulation q2h prn if possible otherwise q3h prn. If breakthrough dose does not last long enough, increase the dose. iii. Opioid adjustments: If > 5 breakthrough doses given in 24h with no improvement in symptoms add ½ the breakthrough to tomorrow’s long acting. iv. Changing to another oral opioid: Calculate total daily dose of opioid (ER + IR) convert using conversion chart and reduce by 25-50% for incomplete cross tolerance, prescribe as indicated. v. Changing from PO to IV: Calculate total daily dose, convert to IV formulation (if not keeping to the same opiate then adjust for incomplete cross tolerance), divide by 24h to get hourly rate or by whatever increment to give (by 6 if giving q4h, by 24 and then again by 10 if giving q6minutes on a PCA). 110 vi. Conversion chart: From Ohio Pain Initiative Card Fentanyl Dosing Based Upon 24 Hour Morphine Requirements Oral 24-hour Morphine use 30-59mg 60-134mg 135-224mg 225-314mg 314-404mg Fentanyl patch dosing 12.5ug 25ug 50ug 75ug 100ug 2. Giving Bad News: a. Know the patient and their chart: Get to know more about them through their SH (family, hobbies, pets, what makes them tick?), FH (how did their family members die? Good deaths?), ask about HCPOA in the SH, the more you normalize it the more normal it becomes to the patients and their families. b. SPIKES mnemonic: Setup be prepared and go in with a plan, Perception find out what the patient/family knows/understands, Invitation find out how much they want to know, Knowledge using layman words, explain the situation, allowing the information to sink in and sitting in the silence that comes afterwards, Empathize say something nice but resist the temptation 111 to make things better by giving false promises/hope, Summarize/Strategize summarize information given, delineate next steps and ensure that everyone understands and is on the same page. c. Remember, physicians speak too much. Allow the patient/family to express themselves d. Document interaction: who was there, what was discussed, what decisions were made *At UH don’t forget the “End of Life Order Set” for patients expected to die imminently. From secretions to anxiety, it reminds you of things we don’t usually think about in other patients. *Keep in mind at UH, that you don’t have to ask every item in the “additional limitations” order set to every family. We can assume a family that doesn’t want added medications or aggressive treatment doesn’t want vasopressors, procedures, intubation. Keep in mind that going through long lists of limitations with families can be traumatic as they see each question as another decision point. Understand the patient’s condition and wishes, and place an order consistent with those. If you’re changing the code status write about the discussion in your note, or write a separate clinical event note. 112 Toxicology: Good Drugs Gone Bad Poison control is available 24/7 at (800) 222-1222. Do not hesitate to contact them if you are suspicious of overdose. ACETAMINOPHEN: Acetaminophen is one of the most common drugs you will see overused, mainly because it is available over the counter. As such, patients often underestimate the amount of damage it can do. The recommended amount of acetaminophen daily is 3g in the normal patient (2g in patients with cirrhosis). Don’t forget to include acetaminophen from combination drugs like Percocet when calculating daily total. Pathophysiology is as follows: • STAGE I (0.5-24 hours after ingestion): Patients may have nausea, vomiting, lethargy. Labs normal. STAGE II (24-72 hours after ingestion): Symptoms improve, but patients start to have • rising transaminases. Patients may develop RUQ pain and coagulopathy as liver begins to fail. • STAGE III (72-96 hours after ingestion): LFTs peak, typically with AST/ALT in the tens of thousands. Patients are jaundiced, coagulopathic, encephalopathic, hypoglycemic, may have lactic acidosis. • STAGE IV (days to weeks after ingestion): Liver begins to recover in surviving patients. Management: • start by obtaining a serum acetaminophen level. Using this level, you can plot patients’ risk of toxicity using the Rumack-Matthew nomogram. Patients should be treated if they fall above the treatment line. • other indications for treatment include single dose >7.5g, unknown ingestion time and APAP level >10, any concurrent liver dysfunction. • if patient presents within 4 hours of ingestion, will benefit from PO activated charcoal administration (1 g/kg, max 50g) unless patient is at high risk of aspiration. There is no clinical benefit to intubating patients only to give activated charcoal. • If patient falls above treatment line, administer N-acetylcysteine (mechanism of action is not clear, but NAC is thought to replete hepatic glutathione stores). • IV and PO treatments available • If patient has any liver dysfunction, they should be treated with IV therapy. • IV —> 150mg/kg loading dose over 60min, then 50 mg/kg over 4 hours, then 100mg/kg over 16 hours • PO —> 140mg/kg loading dose, then 70mg/kg PO q4h for a total of 17 doses • Note there is an order set in the EMR that can make these orders easy! • Consider EARLY hepatology consultation as patients may progress to fulminant hepatic failure and require transplant evaluation! 113 TOXIC ALCOHOLS: Namely ethylene glycol and methanol, toxic alcohol ingestions can be life threatening. These are typically ingested either as intentional overdose or by accident (during moonshining process). Methanol and ethylene glycol are not themselves harmful; it is their metabolites that are toxic. Methanol is broken down to formic acid and ethylene glycol is broken down to glycolate, glycoxylate and oxalate. Presentation: • patients will usually present with profound anion gap metabolic acidosis. • formic acid (methanol metabolite) affects the retina, so patients may have blurry vision. Afferent pupillary defect is ominous sign. • ethylene glycol toxicity can manifest as flank pain or abdominal pain. • patients may have a lactic acidosis but lactate level is not sufficient to cause such profound acidosis Evaluation: • ethylene glycol and methanol levels (these are in EMR as “volatile alcohols” and are actually sent to Akron for processing!) 114 • serum and urine tox to eval for coingestion • blood alcohol level (concurrent ethanol ingestion slows metabolism of EG and methanol) • serum osm to calculate osmolal gap : • Calculated Posm = (2 x plasma [Na]) + [glucose]/18 + [BUN]/2.8 • osm gap = calculated Posm - measured Posm • normal Osm gap is <10; if >10, there is an additional osmolyte contributing Treatment: • administer fomepizole (blocks EtOH dehydrogenase, which creates toxic metabolites): 15 mg/kg loading dose x1, then 10 mg/kg q12h x4, then 15 mg/kg q12h until toxic alcohol level is <20 and patient is asymptomatic (increase dose if patient is on dialysis) • patient should undergo either hemodialysis or CVVH to clear parent compound from the blood • folic acid, thiamine, pyridoxine to aid in the elimination of toxic metabolites • Nephrology consult ETOH: Often the issue with alcohol ingestion isn’t the ingestion itself- it’s what comes after the ingestion stops. Alcohol withdrawal can be life threatening. Alcohol is a depressant which causes an up-regulation of norepinephrine receptors, when patients stop drinking they experience an adrenergic surge which leads to withdrawal symptoms. Minor withdrawal symptoms occur within the first 24-48 hours and include tremulousness, anxiety, GI upset and headache. Withdrawal seizures can occur from 12-48 hours after the last drink. They are often singular. Patients can also have alcoholic hallucinosis from 12-48 hours after the last drink; again, alcoholic hallucinosis is not synonymous with DTs. DTs, or delirium tremens, is the most concerning manifestation of alcohol withdrawal. It is characterized by hemodynamic instability (tachycardia, hypotension) in the setting of acute cessation from alcohol. Patients develop DTs up to 96 hours from their last drink. Mortality is as high as 5%. In order to prevent alcohol withdrawal on the inpatient setting, patients with risk factors for withdrawal are placed on a CIWA protocol. This nursing-administered questionnaire attempts to measure patient’s symptoms of withdrawal and allows for early treatment of withdrawal symptoms with prophylactic benzodiazepines. There are three main pharmacologic choices for starting a patient on a CIWA protocol: • diazepam protocol - typically first line agent because it has a long half life and will selftaper. • lorazepam protocol - use this instead of diazepam if patient is elderly (>65) or if patient has synthetic liver dysfunction (INR >1.3) 115 • phenobarbital protocol - best for use if a patient has concurrent alcohol and benzo abuse; giving phenobarbital instead of a benzo removes any benefit to self-reporting symptoms Ordering a CIWA protocol allows the bedside nurse to give medications for symptoms, so often it will just happen without you even knowing. However, if patient has a CIWA >20, they may benefit from transfer to MICU for closer monitoring. In this case it is often helpful to take the CIWA score yourself to verify the score. Moreover, if you suspect a patient is starting to withdraw from alcohol, give them a dose of benzo regardless of their CIWA score (don’t fall behind early withdrawal). Other issues in the alcohol withdrawal admission: 1. Vitamins (thiamine, folate) 2. Electrolytes (magnesium and potassium are often very low) 3. HTN (clonidine 0.1mg PRN SBP>170 and beta blockers like metoprolol 25mg q6h are common choices) 4. Fluids (may be dehydrated and need boluses, otherwise maintenance D5 1/2NS at 125/hr) 5. Don’t forget these patients are prone to traumatic falls (CT head?), other intoxications (utox). 6. If you suspect meningitis in an alcoholic, cover listeria with ampicillin (along with other meningitis abx). 116 Procedures Case Western is an internal medicine program, not a pre-fellowship observership. Every resident should be able to triage, diagnose, and treat the acutely sick medical patient. This means central lines when your patient needs one, paracentesis when your patient needs one, and lumbar punctures to diagnose meningitis rather than ‘treat empirically’. Occasionally we do thoracentesis with VA attendings or Pulm fellows, but these are less common and won’t be covered here. The NEJM videos are free online and are an excellent way to prep for any procedure. Before all procedures: 1. Are you signed off? (See myevaluations.com for requirements). If not, find someone who is to supervise (co-resident, fellow, chief resident…) 2. At the VA floor procedures need an attending/chief resident for the poke (most common with paras, just ask). Dr. Lopresti is a great thoracentesis teacher at the VA, as are the MICU fellows. 3. Consent: Paper forms at UH, paper or (preferred) computer at the VA. If the patient cannot consent, call the family and have a coresident hear their consent and cosign the form. Crashing patients needing urgent procedures do not need consent, don’t delay an emergent procedure in the MICU/CICU for consent. Unless you have reason to believe they would not want it, stabilize the patient then talk with family. 4. Equipment: Kits for floor procedures (paras, thoras, LPs…) are in clean utility rooms, as are gloves and gowns. In the units they are in designated places, ask your resident. Ultrasound should be used for all procedures (except LPs): paras to see the fluid and avoid bowel, thoras to identify lung parenchyma or loculated effusions, central lines because watching the needle enter the vessel is the best way to protect your patient. 5. Tell the patient’s RN you’re doing the procedure. 6. Time out, say their name/DOB, say what you’re doing. 7. Put chucks under any area that might get fluid, have respect for the RN who cleaned the bed to begin with. After all procedures: 1. Clean up your supplies and the patient. If it’s sharp it goes in the sharps, whether it was used or not. The janitor doesn’t know which needle was used when they get stuck. 2. Tell the RN you’re done. 3. Send all the labeled samples with order recs to the lab. 4. Write a procedure note (at UH ask your resident for their procedure dot phrases) Central Venous Line 1. Sites: Internal Jugular vs Femoral (subclavian less common) 2. Types: Small Bore Triple Lumen vs Dialysis vs Cordis 3. The easiest way to gather the kit your first time is to have your resident show you where it’s at. Most kits come with most necessary equipment, though gloves, 4x4’s, 117 ultrasound probe covers, and often gowns are needed separately at both UH and the VA. The UH trialysis catheters often come without lidocaine (some have it taped to the kit, but these tubes often fall off), so the RN will need to get some for your use. Saline flushes may be included but extra are often helpful. 4. Take a quick ultrasound look at the vessel, ensure you can visualize it and compress it. Make sure there are no clots that should change your site. 5. Arrange the room, get your kit in a position where it can be reached with a single movement. Position your ultrasound screen for easy visibility. Move things that are in the way (ventilators may need moved, IV poles…). Gown up and set up your kit, flushing and locking the ports of the catheter. 6. Position your patient. For IJ, place the patient in trendelenberg, turn head slightly away from side of access. For the femoral approach, place the patient flat and if abdominal fat is an issue use pressure dressing to tape it down (it’ll save you time later). If your patient has respiratory distress and is not intubated, wait till you are ready to introduce the finder needle to drop bed (will need assistant to do this). Or if the patient is very altered or in distress, consider intubating prior to placing line. 7. Prep the area (usually chlorhexadine) at least twice. Quick circle from in to out. 8. Apply sterile drape. 9. Clean once more with chlorhexadine. 10. Apply subcutaneous lidocaine (think placing a PPD), then apply some up to a centimeter down. Aspirate before injecting. 11. Have assistant hand you the ultrasound probe with gel, place sterile sheath. Apply more gel to the outside and use the rubber bands to lock the gel around the head of the probe. 12. Find the target vessel with the ultrasound, if unsure ask a colleague. Insert the introducer needle, aspirating while advancing. Ensure angle is >45 degrees so that the ultrasound will let you watch the needle enter the vein. Once flow is established, remove the syringe from the needle. 13. At this point, various methods are possible to ensure accurate venous placement. A short set of tubing can be attached to the needle and observed that there is no arterial pulsation. Placing your finger over the end to feel is another method. Some institutions even hook up the needle to an A-line kit setup to see the waveform (excessive, but in special circumstances might be useful). 14. Insert the guidewire through the needle. Once the needle is in the vein, never let go of the wire at any point, there is plenty of extra length to avoid both letting go of the guidewire and also keeping your fingers clear of the needle when removing. 15. Visualize the guidewire in the vein using ultrasound. 16. Make a small incision next to the guidewire. Do not cut the guidewire. 17. Dilate the soft tissue with the dilator over the guidewire (for HD and Cordis, dilate with both dilators). 18. Thread the catheter over the guidewire, remove the guidewire in short strokes until in comes out the distal port and then insert the catheter into the skin. Thread the catheter to its desired position and remove the guidewire. 19. Secure the catheter with suture. 20. Aspirate all ports and flush with saline, locking and capping each. 21. Apply sterile dressing. 118 22. Order STAT CXR if IJ. If you did the line, stay until you’ve seen the image and told the RN the line is good to use. Paracentesis (diagnostic or therapeutic) 1.Paracentesis kits are in each clean utility room. Vacutainers are usually available, but are often in short supply. Have gauze, gloves, gown, mask, chlorhex prep. Instead of kit, an 18-20 gauge needle can be used for quick diagnostic taps. 2. Have patient void. 3. Lay patient at 15-20 degrees. 4. Use ultrasounds to visualize ascites in RLQ or LLQ. Avoid superficial blood vessels (come to think of it, avoid all blood vessels). Remember, patients with ascites often also have hepatosplenomegaly, avoid upper quadrants. 5. Arrange room, position ultrasound. 5. Chlorhex the area. 6. Apply sterile drape. 7. Chlorhex again 8. Use assistant to help get sterile probe cover on and find area again. 9. Use lidocaine to inject along area of expected needle course (aspirate before each injection). 10. Pull skin up slightly so hole in skin does not match entry site to ascites (avoid lots of leakage when done). 11. Insert needle (90 degree angle with skin, parallel to the floor). 12. Withdraw fluid. If diagnostic fill all 4 tubes (easily done with one piston syringe, need multiple regular syringes if not using a kit) 13. If therapeutic, set up kit to either drain to gravity or via vacutainer (ask your resident, better seen than written). 14. Remove needle, clean area, apply 4x4. Tell the patient to expect some leakage. 15. If therapeutic, decide if your patient meets criteria for albumin to avoid post procedure hypotension. Labs: Cell count and diff, total protein, albumin, glucose, LDH, gram stain and culture. Occasionally, will need AFB (TB eval) or cytology (need lots of fluid for cytology). Print the recs for the studies you need. At the VA, take sample and recs to basement when you’re done. At UH, small containers can be sent by tube to the lab. Labels on all samples, send recs with them. Lumbar Puncture 1. Theoretically patients without neuro signs don’t need a CT prior to LP, in practice it’s often difficult to fully examine a patient with concern for meningitis and a CT head is usually indicated prior to LP(noncontrasted). 2. Obtain LP kit, chlorhexadine, gloves, facemasks, gowns. Lidocaine is in most of the kits at the VA and UH. 3. We usually use the lateral decubitus position. Have the patient positioned on the bed with their knees pulled towards their chest (an assistant may need to help). 4. Palpate the vertebra at the level of the iliac crest. Identify the intervertebral space. (Better seen than described) 119 5. 6. 7. 8. Cleanse the area with chlorhexadine. Put on sterile gear, open the kit, place the sterile drape over the area. Inject lidocaine in area to be instrumented. Insert needle at 90 degree angle with skin. Advance in general direction of umbilicus> you’ll either hit bone (at that point, redirect) or feel a pop as you enter the subarachnoid space. 9. Obtain opening pressure if desired. 10. Collect spinal fluid in the kit’s tubes. 11. Withdraw needle and clean site. Tell patient to lay flat as much as possible for several hours. 12. Label the tubes and send to lab with order requisitions. Common LP Labs: Tube 1: Cell count and diff Tube 2: glucose, protein (and VDRL/FTA test if suspicious for neurosyphilis) Tube 3: Culture, AFB for TB eval if suspicious Tube 4: Repeat cell count and diff (particularly helpful if initial tube has lots of RBCs) *Thoracentesis and arterial lines are best learned by doing with an experienced person. Do the things listed for all procedures and then learn directly from them their approach. 120 Can I add that on? Test A1c Albumin Aluminum level Amylase ANA B12 Basic Metabolic Panel O Blood lead level NT-proBNP CBC Complete Metabolic Complement (C3/C4) CRP Cyclosporine level D-dimer Drug screen ESR Ferritin Fibrinogen Folic acid level G-6-PD Haptoglobin HCG HCV Genotype HCV RNA/PCR Hemoglobin identification Hepatic Function Hepatitis panel HIV antibody HIV viral load (by AmpliPrep TaqMan) Immunoglobulins Ionized Calcium Iron panel Lactate Lipase Lipid Panel Lithium Level Lupus anticoagulant (DRVVT) Lymphocyte surface markers Add-on Within 5 days 5 days SEND OUT TEST 5 days 5 days 48 hours 48 hours Add-On To Lavender (CBC) Red/Green (RFP) 72 hours 3 days 5 days 5 days Red/Green Red(RFP) Red(RFP) Lavender(CBC) 5 days 3 days 36 hours 48 hours 5 days 5 days 5 days 4 hours 5 days 24 hours 5 days 4 hours 2 days 48 hours 5 days 5 days SEND OUT TEST 72 hours 5 days 5 days No add-on 5 days Can’t add on 5 days 5 days 48 hours 4 hours 72 hours Red/Green(RFP Red-gray serum separator tube Red(RFP) Red/Green(RFP) Green/Lavender (CBC) Red (RFP) Lavender (CBC) Red/Green (RFP) Red/Green(RFP) Red/Green(RFP) Lavender (CBC) Blue (Coag) Red(RFP) Lavender (CBC) Red/Green(RFP) Blue (Coag) Red(RFP) Lavender (CBC) Red/Lavender/Green(RFP) Red/Green(RFP) Red/Lavender(RFP) Red/Lavender(RFP) Lavender(CBC) Red(RFP) Red (RFP) Red(RFP) Red/Green Red (RFP) Blue(Coag) -heparin green top vacutainer, syringe with heparin, lavender or ACD yellow for bone marrow or peripheral blood 121 -sterile vials containing RPMI1640 or viral media for surgical specimens Magnesium Osmolality, serum Potassium Prealbumin Protein C and S PSA PT PTT Renal function panel Reticulocyte count Rheumatoid Factor Rubella titer Serum Protein electrophoresis TCA Levels Testosterone TSH Total T3 Free T4 Transferrin Troponin Type and Cross Type and Screen Uric Acid 5 days 5 days 5 days 5 days 4 hours 48 hours 24 hours 4 hours 48 hours 36 hours 5 days 3 days 5 days 5 days 48 hours 5 days 2 days 5 days 5 days 2 days No add-on No add-on 5 days -sterile container for peritoneal, pleural, spinal, synovial etc samples Red/Green (RFP) Red(RFP) Red/Green (RFP) Red/Green (RFP) Blue (Coag) Red (RFP) Blue (Coag) Blue (Coag) Red/Green(RFP) Lavender (CBC) Red (RFP) Red(RFP) Red (RFP) Red(RFP) Red(RFP) Red/Green(RFP) Red (RFP) Red/Green(RFP) Red (RFP) Red/Green (RFP) Red/Green (RFP) 122 On Campus Food 1.Wolfgang -Great quality, moderate expense, can use ID badge/on call cash -extension 63830 (call ahead and pick up to make it quicker) -Closes at 7PM 2.Cafeteria -closes at 8PM, average quality, ID badge/on call accepted 3.Einsteins (in atrium) -open until 2AM weekdays only (not open weekends) -latest option in the hospital for coffee/bagels/snacks On Call Food Delivery 1. Delivermefood.com -Lots of options, particularly before 9PM. -Tree country bistro, Café Tandoor, Mad Greek all solid options -bit more expensive and takes 45-60 minutes 2. Jimmy Johns -(216) 231-5300 -fast, cheap, filling -if you’ve ordered from them before, make sure they know if you’ve switched hospitals (they associate your phone number with the last location where they delivered to you) 3. Indian Flame -(216) 791-5555 -sharable (one entrée serves 2), affordable, average quality *Chipotle, Panera, Qdoba, Starbucks are all walkable in University Circle, but do not deliver VA: Le Café Du Lounge -24 hours -2nd floor by the PCU -Finest free cheese sticks and Shasta this side of Paris Coffee: Starbucks on Euclid by Seidman Cancer Center Cafeteria Java Jive in Bolwell Resident Lounge has free coffee in both hospitals 123 VA Medical Center Important Phones/Pagers Call 216-791-3800 plus 4-digit extension listed below (p) = Pager HOME CARE/PLACEMENT CLINICS Anticoagulation x5366 Arthritis x5365 Audiology x4090 Cardiology/EP/ Pacemaker x5365 HPBC (Judy Slivika) x4577 Dental x4344/45 CBPC(Diane Pulphus) x4587 Dermatology x4452 CBPC(fax) (216) 707-5920 Diabetes Teaching x4597 ENT x4452 Paging University Hospitals CMC GI x5257/58/59 GU x4491 Dial 9-1-216-207-7244 Gynecology x3425/3724 Then the 5 digit pager. Hepatitis C x5365 Hypertension x3413 PHARMACY x4884/x4379 x5400/x5485 Lipid Medicine Firm A & B x5600 Discharge pharmacy x3632 Non-Formulary Pager (440) 562-2149(p) Mental Health & Addiction x4724/x4725 Satellite Pharm for 3A,3B, 5a x4877/(440)562-1238(p) Nephrology x5365 Sat Pharm for MICU, PCU, 5b x5478/(440) 562-1187(p) Neurology x5654 Hematology/Oncology x3897 CARDIOLOGY SERVICES Optometry x5430/x5445 Echocardiogram x4859, x4904 Orthopedics x5433 Cardiac Cath Main x4857 38848/31650 Cardiac Cath Reading Room x4880 Occupational Therapy 4131/4149/4150 Physical Therapy 4142/4141/4137 Stress Tests x4867/x4855 RESIDENCY AFFAIRS x4452 ECG technician x4870/(440) 562-2354(p) Podiatry Resident Program Office x6537 EP nurse practitioner (440) 562-0552 (p) Pulmonary/Sleep Med x5365 VA Medicine Chief Resident 5034, 31533 (p) Cardiology team pager (440) 562-0361 (p) Scheduling x3044 Ambulatory Chief Resident 5034, 31529 (p) Smoking Cessation x5733 PULMONARY SERVICES Speech Pathology x4090/x4092 LABS Pulmonary Function Testing x4754 MEDICAL RECORDS, FAXES Blood Bank x4083 Respiratory Therapist(Wards)x4753/(440) 562-1544(p) x5232 Blood Gas/Drugs x4061 Respiratory Therapist (MICU) (440) 562-1158(p) Record Control Sleep Lab x4762 Dictations:x839,7676, #1,99999,1,thenSSN Automated Chemistry x5897 Transcriptions: 839,x 7698 / 7326 PROCEDURE LABS/ SERVICES Chemistry x4058 Fax Medicine (216) 231-3289 Coagulation x4086 Dialysis x5181/x5182 Fax ICU (216) 231-3463 Cytology x5142 EEG x 5232 Fax Urgent Care (216) 421-3008 Hematology x4085 EMG Lab x4154 Medical records x5392 x 5258/x5259/x5238 Histology x4064 Endoscopy Lab Medical records fax (216) 231-3295 Mircrobiology x4042 HIV Testing Coordinator x4773/(440) 562-0517(p) ADMITTING & LOGISTICS Geri Rehab NP x4020/(440) 562-0924(p) Morgue x4055 x4212 Bed Control Pathology x4030 Prosthetics x5358, x5648 x 4153/x4123 Escort Phlebotomy x4077 Rehab Medicine x5095 x4423/x5650/x5654 Police x4207/x4208 Urinalysis x4072 Vascular Lab Supply (SPD) x5288 SOCIAL WORK RADIOLOGY x 3061/5362 Kelly Murray (b/g) x4229 Travel Travel (after hours) x4441 Main/Scheduling x4301 Heather Loomis (o/w) x4238 CT x 4323/x3393 Simone Ray (5a/b) x5712 Nursing supervisor pager (440) 562-1157 839, x6685 File Room x4316/x4317 Denise Green (renal) x4248/(440) 562-8686(p) CPRS Help Desk Radiation Therapy x3361/3370 Earlie Williams (supervisor) x4262/(440) 562-0870(p) WARDS Ultrasound x3755 Miranda Payton (Palliative) x4258/(440) 562-1491(p) Ward PCU x5041 MRI x3355 DISCHARGE PLANNERS x5042 Nuclear Medicine x5200 Tammy Magill-Babyak (b/g) x3039/p0033 x5044 Angiography x5585 Marvelyn McKee (o/w) x5054 x5447/p0042 Ward 5A x5051 Maya Hopkins (until 7 p.m.) p0313 Ward 5b (Geri Rehab) WORK/CALL ROOM x5040/x5039 Kimberly Williams (PCU) x3729 MICU/CICU Blue x6162/x6163 SICU 5060/4958/4955 TEAM PAGERS Green x4758/x4774 (440) 562-0509 (p) MISCELLANOUS Orange x4814/x4824 Orange 124 (440) 562-0491 (p) White x5823/x5829 White Green (440) 562-0502 (p) MICU/CICU/PCU x4552/3401/4380 Blue (440) 562-0456 (p) Cards 4772 SP21089(5/11) CONSULTS Anesthesia x 4948/x5120 Dental x4356 Dermatology (440) 562-8588(p) Endocrinology 30113(p) ENT (on call) 30115 (p) Hem/Onc (440) 562-2036(p) HIV nurse(Jan Briggs) (440) 562-0517(p) Infectious Disease (440) 562-8667(p) Neurology 31317 (p) Nephrology (440) 562-8626(p) Neurosurgery (on call) 30170 (p) Opthomology (on call) 30598 (p) Podiatry (440) 562-8693(p) Psychiatry Consult(on call) (440) 562-2194(p) Psychiatry Cons. & Liason (440) 562-2219(p) Skin Care (Terry Langdon) (440) 562-2113(p) Surgery (Cardiothoracic) (440) 562-1492(p) Surgery (General) (440) 562-1778(p) Surgery (Vascular) (440) 562-1777(p) CAT x4725 Home Oxygen Geriatrics x4785/(440) 562-0768(p) x 5267 UNIVERSITY HOSPITALS OF CLEVELAND—216-844-1000 CONSULT PAGERS Anesthesia-Code Pager Cardiology Dermatology Endocrine ENT Heme Onc HIV ID 30189 35213 Fellow pager 31426 30113 30115 30385/31650 31251 38947 35268 31285 32747/31650 COMMAND AND CONTROL Program Director Pager 31552(p) UH Chief Resident 43621, 31250(p) Med/Peds Chief Resident 38455(p) Deena Segal 42562 Barb Bonfiglio 43308, 43811 UHHS HOSPITALS Bedford Medical Center 440-735-3900 Brown Memorial Hospital 440-593-1131 Geauga Regional Hospital 440-269-6000 Heather Hill 440-285-4040 Memorial Hospital of Geneva 440-466-1141 Mercy Medical Center 330-489-1000 Richmond Heights Hospital 440-585-6500 Southwest General Hospital 440-816-8000 St. John’s West Shore Hosp440-835-8000 St. Vincent’s Charity Hosp 216-861-6200 University Hospitals 216-844-1000 Neurology 30116 Neurosurgery 30153 Ob/GYN 30554 Ophthalmology 35251 Pain service-Anesthesia 35879 Pulmonary Fellow pager Psychiatry 30164 RADIOLOGY 32390 Urology 30125 Switchboard/ Control 43062,43063,43064 Wound Care (Becky Roberts) 30417 Angiography 44945 LABS/ PHARMACY Body CT 44940 47051,26221,28836 Triage 4-LABS (45227) Head CT 47680 ABG/Blood Bank 41788/42800 Image Library 47750 Chemistry/Toxicology 45216 MRI Hematology 45244 Nuclear Medicine 43101 Coagulation 45008 Nuclear Medicine Reading Room 26097 Microbiology 43482 PET scanner 43107 Virology 43483 PACS pager 35030(p) Pathology: Autopsy 41836 Radiation Oncology 43103 Cytology 41803 Radiology Junior Resident 45224/32494(p) Surgical 41817 Radiology Specialty Resident 32495(p) Urinalysis 48481 Radiology scheduling 41700 Inpatient Pharmacy 42016 Ultrasound scheduling 43186 Bolwell Pharmacy 47270 University Imaging (Bolwell) 47170 Antibiotic approval 30316(p) IR 48290 ICUS, WARDS, ORs PROCEDURE LABS CICU 42125 Mather OR 42260 43155 MICU 42130 Tower (flr#) 420#0 Cardiac Catheterization 51110 SICU 42120 Lakeside (div#) 415## GI/Endoscopy 43824 NSU 42140 Nursing Sup 30515(p) Echocardiography Dialysis 41585 ICU Nrsng 35500(p) ECG 45518 Electrophysiology 42333 FAX MACHINES Scheduling 43155 DOM 48216 Lakeside 60 41563 EEG 43199 Tower (flr#) Res lounge (216) EMG 41923 420#4 983-3075 Testing 51097/51095 Lakeside 20 41521 CICU 42112 Pulmonary Function 125 48082 Lakeside 40 41523 MICU 42113 Vascular Lab Lakeside 50 41223 Dialysis 48975 PHONE NUMBERS CLINICS Appointment scheduling Cardiology Scheduling Douglas Moore Clinic ElderHealth Heart Failure Clinic 48500 43800 43400 46300 45518 43951 MISCELLANEOUS NUMBERS Admitting 26054/41673/43702 OR/Anesthesia scheduling 42270 (for radiology studies w/ sedation) Broviac scheduling hotline 45346 DACR/NACR – phone 67121 30512(p) Direct Dial-In to UH 844-5344 Emergency Room 43722 Flex Pager 31855 Home Team 4-HOME IV/PICC line team 30278(p) Medical Records 43561 Macdonald 4th Floor 41640 NACR/DACR 67121 Nutrition Therapy 41860 PCOSS Help Desk 43327 Physical Therapy27053(RBC), 28246, 45200 Police 4HELP (44357) Respiratory Therapy Coordinator 30510(p) Risk Management 35626(p) Social Worker On-Call 35138(p) Speech Therapy 45778 Transfer Center 41111 UH Pagers (from inside) 222, then dial pager# UH Pagers (from outside) 464-8410 VA Tie line 203, then dial extension TEAM PAGERS AND PHONES Carpenter Eckel Hellerstein Naff Ratnoff Wearn Weisman FLEX CCLHD Berger Geriatrics 32661 33559 32605 33726, ph 166253 33306 32654, ph 166288 33970 32299 31855 33116 36599 39385
