Clinical Pharmacy Note RE: Stroke

Mar 6/17 1330h Clinical Pharmacy Note RE: Secondary Stroke Prevention

ID: 41 yo male admitted with stroke
(Mar 6 Head CT showed established infarct in L side with no signs of hemorrhage)

S/O: v/s: T 36.5, BP 125/65, HR 76, RR 9

  • RASS -1 to 0, aphasia but still able to answer yes/no questions
  • Aspirin 325mg PR load given at 1720 hr on Mar 5, 17 but 80mg daily is held by neurology until infective endocarditis (IE) can be ruled out with negative BCx
  • Due to previous IVDU (on methadone daily, urine + cannabis, opioids, amphetamines), suspecting septic emboli from IE
    • ECHO for IE w/u pending (currently empirically txed with pip/taz and vanco)
    • BCx prelim, results (Mar 5): G+ cocci likely streptococcus or enterococcus
  • Hgb (Mar 6): 78 (stable)


  • Maintenance aspirin is necessary to help ↓ the risk of early and future recurrent ischemic stroke and ↓ the risk of mortality
  • There are no contraindications to use of aspirin with IE. No suspected intracranial hemorhage
  • Patient has no previous history of CVA or TIA, therefore currently no strong need for clopidogrel
  • No significant drug interactions with ASA (low risk of increased bleeding with escitalopram)

P: Suggest

  • Start ASA 80mg daily (life long). Continue Dalteparin SC (VTE Px dose)
  • Monitor for s/s of ischemic stroke: one-sided weakness, numbness, trouble speaking, trouble seeing, severe headache, confusion
  • Monitor for SEs of ASA: bleeding (tarry stools, hematuria), GI upset, hemorrhagic stroke (severe headache, bizarre behaviour), daily CBCs

Clinical Pharmacy Note RE: Pain Management

Mar 2/17 (1400hr) Clinical Pharmacy Note RE: Pain

ID: 46 yo male admitted with traumatic brain injury and fractures on face and both legs from falling 12ft off a tree


  • v/s: 37.1, HR 90, BP 105/60, RR 21
  • RASS -1 to 0, BPS 5/12, NRS 10/10 (patient regularly banging (not agitated) on side of bed to ask for more pain medication)
  • Ongoing, non-resolving shooting, burning and aching pain to neck and both legs
  • Current pain meds:
    • Dilaudid 0.1-0.5mg IV Q5min PRN (received >20 doses so far today)
    • Dilaudid 1mg OG Q4H regular (started today)
    • Acetaminophen 975mg OG Q6H reg
  • Previous PRN dilaudid IV doses (total daily doses) – Feb 28: 5.8mg, Mar 1: 6.4mg


  • Ongoing pain (likely combination of neuropathic and nociceptive) is not being adequately managed
  • Current regularly scheduled dilaudid OG (total daily dose: 6mg equivalent to 3mg IV) is not adequate in managing pain
  • Pregabalin is effective in managing neuropathic pain and would help decrease requirements for opioids
  • No significant drug interactions with pregabalin

P: Suggest

  • ↑ Dilaudid to 2mg OG Q4H reg (total daily PO dose = 12mg equivalent to 6mg IV)
  • Start pregabalin 75mg OG BID
  • Monitor pain (BPS, NRS) Q4H and use of PRN dilaudid IV daily
  • Monitor for AEs of pregabalin: drowsiness, dizziness, headache, dry mouth, constipation, peripheral edema
  • Monitor for AEs of dilaudid: drowsiness, dry mouth, nausea, vomiting, constipation, urinary retention, pruritus

C3.1 R4(e): Perform & document a vancomycin or aminoglycoside pharmacokinetic interpretation

ID: 42 yo female admitted for query septic arthritis/deep tissue infection/myositis

Current Abx Therapy:

  1. Pip/Taz 3.375mg IV Q6H
  2. Vancomycin 2g IV Loading Dose x 1 dose on August 31 1530
    Currently on 1g IV Q12H (at 330, 1530)

Vital Signs (Sept 2/16): Temp 37.4, BP 119/79, HR 99, RR 18, O2 sats 95% RA
(receives APAP PRN for pain)

↓ WBC (Aug 31: 22.2 –> Sept 2: 10.5)
↓ sCr (Aug 31: 98 –> Sept 2: 45)
↑ eGFR (Aug 31: 62 –> Sept 2: 118)

Micro: MRSA screen pending. Blood Cxs on Aug 31/16 are negative.
Urine Cxs + For E. Coli 90 mega CFU/L

Vanco trough level: 6.2 mg/L (target 15-20mg/L)
– drawn 30 mins prior to Sept 2 330 dose (4th dose, including LD)


  1. Is the drug indicated?: Although patient is improving (decreased WBC, afebrile, improving overall) and is tolerating vancomycin (urinating well, no compliants, sCr stable), cultures are still pending.
  2. Were all the doses given on time?: All doses were given on time
  3. Was the level drawn at steady state?: Trough level was at steady state (pre-4th dose)
  4. Was the level drawn appropriately?: Level was drawn appropriately 30 mins prior to the 4th dose
  5. Assess the level: Vanco trough level = 6.2, which is below target

P: As discussed with MD:

  1. Discontinue previous vancomycin IV orders.
  2. Increase vancomycin to 1.25g IV Q8H – next dose due at 1530 today
  3. Vancomycin level on Sept 3 at 1500 (30 mins prior to 1530 dose)
  4. Will continue to monitor: renal function, temperature, pain/swelling, WBC, CRP
  5. Pharmacy will continue to follow and adjust dose accordingly. MD to reassess need for vancomycin.

Rationale for vancomycin 1.25g IV Q8H:

  • Improving renal function requires increased frequency (Q8H) to ensure concentrations stay above vancomycin’s MIC
  • Following linear pharmacokinetics:
    • Would expect that we would need to target a daily dose of ~5500mg
      (~1800g IV Q8H)
  • Although we want to ideally target 15-20mg/L, the benefits of ~doubling the dose to target 15-20mg/L likely won’t outweigh the risks (e.g. risk of accumulation
    → increased risk of nephrotoxicity and ototoxicity) when the patient is already improving at a significantly sub-therapeutic level.
  • Therefore: ↑ dosing frequency and ↑ the dose by 250mg (minimum dosing increment)
  • Keeping in mind: patient improving at sub-therapeutic level may indicate that patient is improving on other antibiotic therapy and that coverage against MRSA may not be warranted. Pharmacy should follow up with MRSA screen.