Presentation on CIWA Protocol:

Diagnostic Tests Used:
CT Scan
MRI: A noninvasive technique for visualizing many different body tissues. Unlike x-rays, MRI does not use any radiation. Instead, it uses radio waves, a large magnet, and a computer to create images.As with a CT scan, which does use x-rays, each MRI picture shows a different “slice,” or cross-section, of the area being viewed. An MRI of the brain can identify tumors and areas of brain damage caused by a stroke or another neurological condition.

Echocardiogram: Ultrasound of the heart to examine heart valves, how forcefully heart pumps blood, determine the size of heart, and assess how well it is functioning. It can spot areas of the heart wall that have been injured by a previous heart attack or some other cause.
TTE: Transthoracic echocardiography is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function. The test is useful for assessing the size of the heart chambers and walls, heart muscle function, heart valve function, blood clots or masses in the heart, fluid around the heart, presence of holes or defects between the heart chambers, and abnormalities of blood flow within the heart.

TEE: A type of echo test in which the ultrasound transducer, positioned on an endoscope, is guided down the patient’s throat into the esophagus. The TEE test provides a close look at the heart’s valves and chambers, without interference from the ribs or lungs. TEE is often used when the results from standard echo tests are not sufficient, or when doctor wants a closer look at the heart. TEE may be combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart’s valves.

Doppler ultra-sound: A noninvasive test that can be used to measure your blood flow and blood pressure by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells.
Chest X-Ray

Topics discussed:

Clindamycin use in cellulitis, necrotizing fascitis: appears to have an anti-toxin effect against toxin elaborating strains of streptococci and staphylococci.
Clinicians should consider the possibility of laboratory error, sampling error or blood-sample hemolysis before initiating therapy, especially when patient is asymptomatic and electrolytes were previously normal with little or no change in therapies or clinical condition.
Major organ involved in electrolyte and fluid hemostasis: kidney
Recommended to use adjusted body weight in obese adult patients
AdjBW(men) = ([wt in kg – IBW in kg] x 0.3) + IBW)
AdjBW(women) = ([wt in kg – IBW in kg] x 0.25) + IBW)

Serum osmolality: (2 x serum sodium conc. in meq/L) + (serum urea conc. in mg/dL/2.8) + (serum glucose conc. in mg/dL/18)

Hyponatremia: Symptoms: headache, lethargy, disorientation, restlessness, nausea, vomiting, muscle cramps or weakness, depressed reflexes, seizures, coma, death, altered mental status, seizures. Identify and correct reversible cause of hyponatremia e.g. excessive i.v. administration of hypotonic fluids, such as 5% dextrose injection.

Hypertonic normal saline is a dangerous medication as incorrect rate and volume can lead to permanent neurologic complications, including central pontine myelinolysis which manifests as a gradual onset of neurologic alterations occurring within 1-6 days of rapid correction. Findings may include pseudobulbar palsy, quadriparesis, seizures, and movement disorders. [Source: Treatment of electrolyte disorders in adult patients in the intensive care unit Am J Health-Syst Pharm Vol 62, 2005]. My preceptor shared some real stories and went over the calculations with me on how to find out if the order is safe or not. The maximum recommended increase in serum sodium concentration is 8-12 meq/L per 24 hours with complete correction over 48-96 hours. Serum sodium levels should be monitored frequently (e.g. q 2-4 hrs) until the patient is asymptomatic, then q 4-8 hrs until the serum sodium is WNL.

Amount of Na in 1 L of 3% NaCl = 512 meq, 1 L of 0.9% NaCl = 154 meq/L

Types of potassium salts used in hypokalemia


Signs/Symptoms/Questions I would ask/laboratory investigations/treatment procedure
Acetaminophen Toxicity, Salicylate Toxicity, Ethylene glycol Toxicity
Know what dose is lethal, how would you treat it, timeline (e.g. when was the drug ingested) is very important in determining how to treat

Indications for use of IVC filter: http://emedicine.medscape.com/article/419796-overview#showall

Treatable causes
5Hs: Hypothermia, hypoglycemia, acidosis, hypo or hyperkalemia, hypovolemia
5Ts: Cardiac tamponade, toxins, tension pneumothorax, thrombosis coronary, thrombosis pulmonary

Clinical Interventions:
Dose adjustment according to renal function of piperacillin/tazobactam
Vancomycin/Phenytoin/Digoxin pharmacokinetics
CIWA Protocol: suggested to discontinue
Warfarin dosing
Discontinuation of linezolid (not required as no evidence of endocarditis)
Streamlining of antibiotics
Assistance with adherence (called patient’s pharmacy to inform about patient’s decision to get her medications blister-packed)
Called Pharmanet to request special authority
Educated patient on how to use MDIs
Medication Reconciliation
Improvement in Triaging: More efficient with time

About rajwantminhas

I just finished my pharmacy degree at UBC. I am excited to be part of Lower Mainland Pharmacy Services. My goal is to get exposed to different kinds of disease states, medications and become better at applying my knowledge. Patient interaction is another aspect that I am going to strive to get better at. I am looking forward to this intense year and learning tonnes!

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