Last day at LGH today for the medicine rotation. I am sad to see it end. The staff at the LGH have all been extremely friendly and supportively towards my learning. I will miss them alot.
Yesterday, I received news from Beth that one of my patients had passed away after been transferred to SPH. He had a history of alcoholic cirrhosis and was awaiting a liver transplant. Unfortunately, his kidney made a turn for the worse on Wednesday and he passed away later that evening. I feel very sad for the patient and his wife.
Didatic on alcohol withdrawal:
- DMS IV: dependence: ( 3 of following): tolerance, withdrawal, use more or longer than intended….
- Abuse: example being social problems–> essentially, it is anything that affects functionality
- mild withdrawal: sx in 0-48 hr, peak 24-48 hr, resolve: 48-72 hr
- 40% pt die if not treated: mostly from CV reasons or metabolic disturbances or infections
- DT: delirium tremens: delirium, horors, fears, disorientation, tremors, hallunciations, diarrhea anxiety
- CAGE: cut down, annoyed, guilty, eye opener
- agitation is the most common side effect
- CIWA: clinical institute withdrawal assessment for alcohol
- disadvantage of CIWA: need to communicate ( sedated patient or language barrier)
- advantage of CIWA: prn
- evidence for CIWA: decrease treatment duration, decrease BDZ dose, decrease sx
- reason for thiamine: (1) thiamine deficiency (2) wernicke’s encephalopathy: ataxia, confusion, memory problems, eye paralysis
- thiamine is found in grains and eggs, some patients are put on multivit ( help with other nutritional deficiency- ex. B12)
- CIWA protocol : option A: diazepam, option B: lorazepam
- lorazepam is more easily broken down compared to diazepam in renal/hepatic impairment
- lorazepam has less risk of respiratory depression on diazepam
- MOA of alcohol withdrawaL: alcohol bind gaba, gaba is an inhibitor, increase stimulation from SNS –> seizure, gaba is up regulator b/c of alcohol ; therefore, more gaba receptors; bdz bind gaba receptor
- watch for decrease opioid or pt will be over sedated
- overadherence of CIWA: agitated for other reasons
- CIWA protocol : duration of 5 days usually
Case presentation today
The presenation went well today. The pharmacists asked lots of thought provoking question about the case, which led me to think of other alternatives and also to question my own recommendation. The case was a discussion about the use of clopidogrel and ASA combination for a post MI patient. I discussed a few trials, including the MATCH, CHARISMA and CAPRIE trial. I think that I will spend more time looking into the recent landmark trials discussion the interaction between clopidogrel and PPI. These studies will play a significant role in the interpretation of the case. It would also be more helpful if I can remember specific population inclusion criterias and the absolute event rates for the trials included. One of the pharmacist also explained to me that the CAPRIE trial was not an ITT trial. When he recalculated the numbers, the data was not ss. The absolute risk is likely very miniscule, or less than 1%.
Procedure Log:
I was able to order a pre and post level for a new gent dosing for a patient. The patient has renal impairment and we were not sure how the medication was going to be cleared. In addition, the patient is also a very big, tall man, so conventional dosing may not be appropriate.
Secondly, I was able to interpret a digoxin level for the same patient. The level came back as 2.1 and it was taken 19 hours post dose, which is within the ideal 12 to 25 hour range. The target for our elderly patient is less than 1 to 1.5 because he is experiencing sx of weakness and anorexia when he was first admitted. Digoxin experiences linear pharmacokinetics. His current dose is 250mcg daily. Our patient weights 170 lbs, IBW: 86.8. It was suggested that the patient’s dose be decreased to 185.7 mcg daily to achieve a trough digoxin dose of approx 1.5. We would then monitor the patient for sx improvement and heart rate control. Bisoprolol was also added to the patients’s current therapy for better rate control.
Areas of improvement for the future:
1. Pay attention to the small details when doing a work up… they can make a big difference!
2. Try to go the next level with your formal topics… memorization or better understanding will help you apply the knowledge to your patients.
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