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

Emergency so far…


Gradually, I am learning to be skeptical about everything as the key is to question everything unless you are convinced why something is being done. Physicians are great at diagnosis but it is my role as a pharmacist to make sure everything pertaining to medications is being taken care of. My preceptor has shared many real examples from her practice which have made me realize how important it is to convince myself. For example, if someone has recently been diagnosed with atrial fibrillation and I have been asked to anticoagulate the person, I am not just going to blindly follow that. It is my responsibility to ask is this drug even indicated, is the dose effective and safe. May be the patient has hypethyroidism which can be treated before I think of starting an anti-coagulant.
As a licensed practitioner, I have the right to say no when something doesn’t make sense to me and I feel it is unsafe for the patient. For example, my preceptor shared a case where a patient was put on ASA, plavix, warfarin and heparin all simultaneously in an acute stroke. Even if the physician disagrees with me, I need to voice my opinion and chart my role in the process.

Topics discussed:
Advanced Cardiac Life Support
Phenytoin dosing

Wrote notes in the chart re:
Digoxin, warfarin and phenytoin dosing

Emergency is a busy atmosphere but I find it very rewarding as it provides me to exposure to lots of different disease states. I am being given the opportunity to talk to different physicians and make changes to the orders. This is being very helpful as my communication skills and confidence will only improve with more practice.

Emergency Medicine: Week 1



1. Pharmacokinetic interpretation and documentation of phenytoin levels for at least 1 patient
2. Pharmacokinetic interpretation and documentation of vancomycin and aminoglycosides of at least 2 patients
3. Read and discuss topics with my preceptor on: electrolyte imbalances, seizures, stroke
4. Apply concepts of electrolyte imbalance treatment and work up at least one patient

This week I did not get to spend much time on the ward due to job fair and exam.
Monday: Orientation, Patient Triage introduction, worked up one patient with hypernatremia
Thursday: Worked up one patient, attended a presentation at a local high school by my preceptor exposing high school students to role of a hospital pharmacist as part of the Pharmacist Awareness Week
Topic discussed: Diabetic Ketoacidosis in Adults
Friday: Triage, Followed up one patient from Thursday, worked up a new patient

Concepts/terms I looked up so far:

1. Double disk diffusion test: Performed for the detection of inducible clindamycin resistance. Some isolates of Staphylococcus aureus have in vitro resistance to erythromycin and susceptible to clindamycin.
The disk diffusion (D-test) method can detect S. aureus isolates with inducible macrolide-lincosamide-streptogramin B (iMLSB) resistance.

2. Plt clumps/EDTA:EDTA-induced platelet clumping is possibly the most common cause of pseudothrombocytopenia. EDTA (ethylenediaminetetraacetic acid) is the most commonly used anticoagulant in evacuated tubes. EDTA reduces platelet activation by protecting the platelets during contact with the glass tube that may initiate platelet activation. Activation causes platelets to clump in the presence of calcium and platelets adhere to the glass surface at a rapid rate. Chelation of calcium using EDTA results in decreased platelet adhesion or retention to glass.

3. GJ feeding tube: gastro-jejunal feeding tube.
Medication administration through enteral feeding tubes: http://www.medscape.com/viewarticle/585397

4. IVC filter: http://www.guidelines.gov/content.aspx?id=15730

Cannulation is the process whereby a cannula (a small hollow plastic tube) is inserted into and kept inside the vein for a period of time.

5. Evidence behind use of CCBs in heart failure:

6. Troponin I timeline: http://www.ecmaj.ca/content/173/10/1191.full

7. Uncapping dalteparin: LMWH in Renal impairment and Obesity

8. Prolia (Denosumab): Can cause hypocalcemia (symptoms: Spasms, twitches, or cramps in muscles, numbness or tingling in fingers, toes, or around mouth)

9. ESBL treatment: Carbapenems are the most reliable and most effective. Among the available carbepenems, meropenem is the most active against ESBL-producing organisms in vitro, with MICs generally lower than those of imipenem (0.03-0.12 µg/ml vs 0.06-0.5 µg/ml).

10. Aspiration pneumonia antibiotics (Source: Bugs and Drugs)
Community-acquired or nursing home acquired pathogens: S. pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae (Alcoholism and enteral feeding may be risk factors for colonization with these organisms)
Antibiotics recommended: Cefuroxime IV/PO 2. Gatifloxacin or Levofloxacin or Moxifloxacin for 7-10 days

Community-acquired or nursing home acquired with poor oral hygiene, severe periodontal disease, putrid sputum: S pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae, Oral anaerobes, Streptococcus spp, Eikenella corrodens
Amoxicillin-clavulanate or Cefuroxime IV/PO + Metronidazole Iv/PO
Gatifloxacin or levofloxacin or moxifloxacin + metronidazole IV/PO
Treat for 7-14 days

11. BOOP (Bronchiolitis obliterans with organizing pneumonia): A rare lung condition in which bronchioles and alveoli become inflamed and plugged with connective tissue. The disorder is also known as cryptogenic organizing pneumonia (COP). Associated with other health conditions:
Infections. BOOP sometimes occurs after people have had certain infections, including chlamydia, influenza or malaria. (2) Inflammatory disorders: Risk appears to be heightened for people who have disorders such as lupus, rheumatoid arthritis or scleroderma. (3) Chemotherapy or radiation can put you at risk of developing BOOP. (4) Transplanted tissue. Bone marrow, lung, kidney and stem cell transplants sometimes trigger bronchiolitis obliterans with organizing pneumonia. (5)Drug exposure (include cocaine, gold salts and some antibiotics and anti-seizure medications).

Most people recover after weeks or months of treatment prednison but in some it can progress in spite of treatment. Source: MayoClinic

12. Glicliazide and renal insufficiency: Avoid renal function of 10-50 ml/min and <10 ml/min
Source: Dosing guidelines for Adults:
13. Phenytoin:
Dose related side effects: drowsiness, confusion, nystagmus, ataxia, slurred speech, nausea, unusual behavior, mental changes, coma
Non-dose related side effects: hirsutism, acne, gingival hyperplasia, folate deficiency, osteomalacia, hyper-sensitivity reactions, steven-johnson syndrome

Pediatrics Final Week


Overall, this rotation was a great learning experience. Lots of lessons learned for the future!

Feedback received regarding journal club and case presentation is in the handout. Feedback

Interesting case: Patient on ketogenic diet for seizure prophylaxis. As a pharmacist, my role was to make sure to use medicines that do not add excessive glucose to her total intake.

Other tasks performedEpipen teaching
Making phenobarbital suspension from tablets
Gentamicin levels x 2
Vancomycin levels x 2

Topics discussed

Things to keep in mind:
Check the date and time of diagnostic tests
Report and write the dose in mg/kg
Be aware of when the last dose of antibiotics is?
You are the drug expert! Prove to yourself why a certain drug is on patient’s profile. If you cannot, question it!
Be convicted in your recommendation
Use primary literature vs. tertiary
Pharmacists are paid to think, you are the problem solver!

Summary of jaundice from a handout:
Not a disease, it is a symptoms. It is common in new-borns and in most cases, is a natural part of the newborn’s adjustment to life after birth. May make a baby sleepy and slow to feed, but it rarely causes any problems.
RBC breakdown–bilirubin–eliminated by liver–immature liver–accumulation of bilirubin
Other causes of jaundice:
Premature baby
Infection: may reduce liver’s efficiency
Bruising: bruising during the birth process can result in a larger than usual amount of bilirubin
Mother and baby-blood incompatability
Phototherapy: light changes bilirubin into a harmless chemical. Baby will require more frequent feedings to replace fluids lost through phototherapy.
Breast milk jaundice, occurs in about 1%, cannot be diagnosed until the 2nd week of life.

Pediatrics Week 2 and 3


Tasks performed:

Vancomycin Calculations
Gentamicin Calculations
Antibiotic teaching to medical students with my preceptor
Witnessed lumbar puncture on the pediatric ward
Counselled patient and family on blood pressure medications (patient had a pacemaker)
Attended daily patient care rounds

Journal Club JCPediatrics Rotation Vicks Vaporub vs. petrolatum vs. no treatment
Rx Files Summary: http://www.rxfiles.ca/rxfiles/uploads/documents/OTC-Vapor-Rub-Trial-Summary.pdf

Drug Information Questions:

Why do infants not acquire C. difficile infection even though most of them are colonized with it?

Clinical infection is rarely reported in infants as their gut is not sensitive to the effect of toxin A and B (toxins bind to receptors on the luminal-facing plasma membrane of colonocytes). After 1-2 years, the C difficile carrier state disappears and the child acquires barrier flora. Other proposed mechanisms:
1. Relatively low numbers for the pathogen in the infant gut
2. Preferential colonization of the infant by nontoxigenic or less pathogenic C difficile strains
3. Absence of toxin receptors or downstream signaling pathways in the immature gut mucosa, and protective factors in breast milk and neonatal gut flora.

Source: http://journals.lww.com/jpgn/Fulltext/2010/07000/Asymptomatic_Colonization_by_Clostridium_difficile.2.aspx

Topics discussed:

1. Neonatal sepsis (risk factors, treatment)
Risk factors for early onset neonatal sepsis:
Over 18 hour rupture of membranes
Pyrexia >38 C
Premature labour @ <36 weeks
GBS bacteriuria at anytime during pregnancy
Previous child with invasive GBS disease

2. Meningitis (risk factors, common pathogens, treatment, chemoprophylaxis)
3. Attended asthma device teaching conducted by my preceptor to Family Practice Residents
Inform parents that untreated asthma results in shorter height vs. in patients who use steroids for asthma control
If the child is crying, it is better as deeper breathing leads to more drug deposition.

4. Vitamin D requirements in children: According to the dietitian all babies birth to 12 months of age need 400 IU of Vitamin D every day. Breastfed babies need vitamin D from supplements but formula-fed babies get it from infant formula: 1000 mL of formula has 400 IU of vitamin D. If the baby drinks both breast milk and formula, he needs 400 IU of vitamin D supplement every day. Breastfed toddlers 12 months and older need 600 IU of vitamin D every day.
5. Dehydration

Midpoint evaluation, strong points:
– Responsiveness to feedback (willingness to "try new things")
– Eager to learn and once taught, can apply the knowledge
– Ability to self-reflect, set goals for herself and strive to make herself better in terms of clinical pharmacotherapeutics

Most of the pediatric patients reach steady state around third dose unless in renal failure
Hallmarks of bronchiolitis: Wheeze + crackles
Vomiting can lead to metabolic alkalosis
Normal weight gain in neonates: 20-30 g/day

Dehydration signs/symptoms:
CNS: Lethargy or coma (with severe dehydration)
HEENT:sunken fontanelle, little or no tears, sunken eyes, dry or sticky mouth
CVS: low BP, rapid heart rate, decrease in blood pressure from sitting down to standing up
RR: Tachypnea
GI/GU/Renal: low urine output, harder stools, increase in BUN and SCr, ketones in urine
MSK/Skin/Extremities: poor skin turgor, delayed capillary refill
Fluids/Lytes/Heme: increase in sodium
Goals for my last week:

1. To speak more loudly and confidently during rounds
2. Be more proactive in my approach while working up the patient. Questions to think about: What can happen? What are the options if the patient does not improve on the current regimen? What if the IV line comes out?
3. As pharmacists we are drug experts, use your knowledge of pharmacokinetics and pharmacodynamics to make the best possible decision for the patient.
4. Try my best to engage the patients and interact with them as if they weren't sick. I love kids and I felt the first two weeks, it didn't show while interacting with me. I just need to be normal self and talk to them like I do with other kids.
5. The more patients I see, the more practice I do the better it would be for me in the future.
6. No to rely on others to help me come up with the FINAL solution/recommendation. I need to improve on not "second guessing herself". The patients I am following are MY patients, therefore I am responsible for any decisions or outcomes.
7. Identifying DRPs and priortizing them

Pediatrics Week 1



1. Perform and document a pharmacokinetic interpretation of at least one drug besides vancomycin, aminoglycosides
2. Perform and document a vancomycin pharmacokinetic interpretation
3. Provide continuity of care from in-hospital to outpatient setting to at least 1 patient
4. Clarify at least 2 medication orders with the prescriber
5. Counsel caregivers on at least two medications
6. Perform at least one nursing in service
7. Gain understanding of immunizations in pediatrics

Disease conditions worked up so far:
Neonatal lupus
Diabetic Ketoacidosis
Primary ciliary dyskinesia, Bronchiectasis

Presentations attended:
Antibiotic teaching to nursing students by my preceptor
Journal Club by Herb Wong: Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial

Topics discussed with my preceptor so far:
Developmental Pharmacology: Drug disposition, action, and therapy in infants and children
Immunizations to be administered in grade 9: Tetanus, Diphtheria, Pertussis Vaccine

Ketoacidosis: high anion-gap metabolic acidosis due to excessive blood conc. of ketone bodies
Ketoacidosis can be seen in following conditions:
starvation ketosis (In adults it can take 3-14 days of starvation to reach maximal velocity, could be 4 hrs in kids, even if they miss 2 feeds)
Alcoholic ketoacidosis
Diabetic ketoacidosis

Psychiatry Final Week


Tasks performed:
In-service to Psychiatrists, nurses and pharmacists on Memantine + antipsychotics

Memantine Presentation Final

Case presentation: Pisa syndrome

Psych case presentation Final

Counselled two patients on their medications

Clinical Pearls:
Take a lithium level on any patient on Li on admission (2) aim for lower levels in elderly population
Terms I get confused about:
Dystonia: neurological movement disorder in which sustained muscle contractions cause twitching and repetitive movements or abnormal postures. Two forms: acute and delayed

Patient is defined as having metabolic syndrome if the patient has central obesity plus 2 of the following 4 risk factors; elevated triglycerides, reduced HDL, elevated BP, elevated blood glucose

Cardiometabolic monitoring form used by BC Mental Health and Addiction Services monitors for following:
Waist circumference, weight, BMI, blood pressure, fasting blood glucose, Hgb A1c, LDL cholesterol, Total cholesterol, HDL cholesterol, triglycerides, Cholesterol/HDL ratio, ECG abnormalities, QTc

Goals for next rotation:

See more patients: Aim for 1 new patient every day
Follow-up with patients everyday