@mmontg21 on GrepMed

Adult Vancomycin Guidelines The information below provides general dosing guidelines for vancomycin. A maintenance regimen of 15-20 mg/kg/dose with the frequency determined by current creatinine clearance is the accepted dosing method. There is no clinical utility of peak serum concentrations, and therefore these should not be routinely measured. Serum trough concentrations should be routinely measured and serve as a surrogate indicator of the AUC: MIC ratio.1 Dosing in renal impairment requires changes in dosing and monitoring methods and often requires a detailed reference source and nephrology consultation. Although vancomycin has been associated with nephrotoxicity and acute kidney injury, causality has not been confirmed, especially in complex critically ill patients. #Management #Pharmacology #Vancomycin #Dosing #Loading #Maintenance #Trough #Targets #Levels

Cardiac Valve Replacement - Anticoagulation INR Targets and Antiplatelet by Valve Type Bioprosthetic valves require at least 3 months (up to 6 mo) of vitamin K antagonist (VKA) with a goal INR 2.5, plus aspirin (ASA) 75-100 mg daily. VKA can be stopped after 3 months, but ASA 75-100 mg daily should be continued lifelong as monotherapy (2017 AHA/ACC VHD Guidelines). Three to six months are required for endothelialization of the bioprosthetic valve. Note: some experts utilize direct oral anticoagulants (DOACs) for bioprosthetic valves since these agents have been studied in patients with chronic atrial fibrillation and a bioprosthetic valve (2017 AHA/ACC VHD Guidelines Section 2.4.3; UpToDate Anticoagulation in Prosthetic Valves ). #Management #Cardiology #Prosthetic #Valve #Anticoagulation #Bioprosthetic #Mechanical #Guidelines #INR #Target #DOAC #Table #Replacement

Current guidelines for outpatient treatment of Community Acquired Pnemonia (CAP) #Management #Outpatient #CAP #Community #Acquired #Pneumonia #Antibiotics #Treatment #Regimen

ICU Pre-Rounding Bundle Checklist VITALS: trends! • Important to know if the pt is getting better or worse 9 don't forget context! • Write down your vitals all together, but know they are in the context of drips (BP/HR) and the vent (RR/SpO2) • If your VS changes, it's important to know if the drips or vent have changed. VENT: mode + settings + what the patient is doing (breathing over? dyssynchronous? how?) • AC/VC (VTE/RR/PEEP/FiO2; know actual RR, and P plateau) • AC/PC (PC/PEEP/RR/FiO2; know actual RR, exhaled volumes: VTE) • On SBT? If so, know PS, PEEP, Pt's own RR, FiO2, VTE and RSBI, and if they failed, know why! DRIPS: trends! (how long on/off, increased/decreased, response) • Sedation: know RASS + goal (+/- CAM-ICU) • Pressor: know BPs, HR, UOP (see below) I+Os: trends! 24hr total + NET + for hospitalization • INS: what's their main source of ins? (drips, abx, transfusions, feeds - PO or parenteral - ie PPN/TPN?) • OUTS: UOP (total and hourly, note if it is rapidly dropping off), CRRT (total and hourly net negative), • iHD (how much out in a session?), BMs (know last BM/how many per 24 hrs. and bowel regimen) ABX: day #? total course length? new/updated culture data? STEROIDS: day #? total course length? taper? PPX: GI, DVT, ABX (ppx for chronically immunosuppressed - transplant, HIV, etc.)? EXAM / LABS / IMAGING: trends! + changes/new findings LINES / TUBES: know gauges, types, and locations Dr. Meredith Greer @EmmGeezee #ICU #PreRounding #Bundle #Checklist #CriticalCare #Management

Admitting in the ICU - Checklist VITALS: If bad, stop and go see the patient immediately; you can always review the chart at bedside! LABS: Baseline + new (you can start making a problem list here, ie hyponatremia, AKI, etc.) IMAGING: Always compare new to prior & make sure you look at the imaging yourself! TTE: Helps to know if the pt has pre-existing heart failure, esp in work-up/management of shock MICRO: Make sure cultures ordered if indicated, also helpful to know priors (don't miss MDR bugs) MEDS: Quick review can help you figure out the Pt's PMH; consider withdrawal or overdose of home meds! Floor transfer? - Could anything they've been given be contributing to current decompensation? NOTES: The last clinic note, discharge summary, and ED triage notes are usually good places to look quickly BUT, be careful not to spend too much on them prior to seeing the patient REMEMBER, something has acutely changed, and they're sick! Make your own objective assessment of the Pt's current clinical status & ensure they're stabilized THEN feel free to dive deep into notes and speak with family for more history Initial Work-up: • For most ICU pts a CBC and CMP is a good place to start. • Most will also get an EKG and CXR. • And an initial bedside echo is never a bad idea - make sure to report your findings in your H&P! Other Things to Consider (depending on the clinical scenario): • Lactate, Troponin, TSH, CPK, HIV, EtOH, Urine Pregnancy Test, UTox Dr. Meredith Greer @EmmGeezee #Admitting #Admissions #ICU #Pearls #Checklist #diagnosis #workup #criticalcare

Hospitalization for the Evaluation of Patients with Low Risk Chest Pain Choosing Wisely: Things We Do For No Reason https://www.journalofhospitalmedicine.com/jhospmed/article/157584/hospital-medicine/things-we-do-no-reason-hospitalization-evaluation-patients Visual Abstract by Dr. Charlie M. Wray https://twitter.com/WrayCharles #Admission #Hospitalization #LowRisk #ChestPain #TWDFNR #Management #EBM #VisualAbstract #ChoosingWisely

Liver Chemistries - Interpretation of LFTs R-value: Serum (ALT/ULN ALT) / (Alk phos/ULN ALP) • R > 5: Hepatocellular - Check Acute viral hepatitis serologies, HCV RNA • R 2-5: Mixed - Check Acute viral hepatitis serologies, HCV RNA • R < 2: Cholestasis / Obstructive - Check Obtain imaging studies Imperative to Identify Acute Liver Failure (ALF): • Liver injury < 26 weeks • INR > 1.5 • Encephalopathy Cellular Destruction: Hepatocellular Level • AST: Less specific to liver than ALT • ALT: Specific to liver than AST • GGT: - Specific to liver - Assists in liver specificity to elevated ALP • AST/ALT > ALP: Typical of hepatocellular injury • Bilirubin - +/- elevation Obstruction: Cholestasis • ALP - Surface of bile duct epithelia - Cholestasis/Bile salts augment synthesis of ALP - Due to synthesis - rises later - Half life: 1 week • Direct bilirubin: ↑ • AST: ↑ • ALT: ↑ • GGT/5-NT: ↑ • ALP > AST/ALT: typical of cholestatic disease • If ALP ↑: Check GGT & 5-nucleotidase (5-NT) - If both are normal - ALP is from extrahepatic source Production: • Albumin • Coagulation factors: PT/INR Infiltrative - The liver is invaded or replaced by non-hepatic substances, such as neoplasm or amyloid: • Elevation of ALP • Near normal AST/ALT AST:ALT Ratios: • Alcoholic liver disease: > 2 • NASH, Chronic viral hepatitis: < 1 • Cirrhosis: > 1 • Acute muscle injury: > 3 • Chronic muscle injury: ~ 1 Nonhepatic Source of Liver Enzyme Elevation: • Bilirubin: RBC (hemolysis, bleeding, hematoma) • AST: Skeletal muscle, cardiac muscle, RBC, Kidney, Brain • ALT: Skeletal muscle, Cardiac muscle, Kidneys • LDH: Heart, RBC (hemolysis) • ALP: Bone, First trimester placenta, kidneys, intestines, White blood cells Unconjugated Bili > 90% of Total Bili Etiology: • Gilbert's syndrome • Hemolysis #liver #chemistry #diagnosis #differential #Hepatology #transaminitis #LFTs #RValue #interpretation

Features of Components of Liver Function Tests #Diagnosis #IM #GI #LFTs #Liver #Function #Tests #Locations #AlkPhos #AST #ALT #Ddxof

Hepatopulmonary Syndrome (HPS) Diagnosis Algorithm Bubble echo is the first piece of the puzzle. The nail on the dx is an A-a gradient >15. If <15 it is a simple intrapulmonary vasodilation which can present the same way on bubble echo. Themis Kourkoumpetis, MD, MPH @Themis_Kourk #Hepatopulmonary #Syndrome #HPS #Diagnosis #Algorithm #hepatology #pulmonary

The Liver Consult Primer - Guide to calling a consult HPI: - Start with reason for consult - 1-liner summary - Important findings: jaundice, coagulopathy, AMS - Reason for admission (if different) PMHx: - Focus on prior Liver/Gl History - Cirrhosis & complications/ MELD - Prior GI surgeries, TIPS, paracentesis - Prior endoscopy & endoscopist (GEV or PHG) Data: - Vitals - LFTs, plt, INR, GTT, indirect bili/ current MELD - Chronic liver disease work up - Liver US - Prior liver biopsy Meds: - Outpatient meds (NSBB, diuretics, lactulose) - Any prior hepatotoxic meds (tylenol, anti-bx) - EtOH history (pattern and amount) Course: - Brief hospital course - Episodes of hypotension, shock, sepsis, GIB etc Gregory Brennan MD https://twitter.com/GregoryTBrennan #Liver #Consultation #GIConsult #Primer #Calling #Referral #Hepatology #Gastroenterology