C3.5 R2: Prepare and deliver educational seminar to pharmacists #3

For my surgery rotation, I presented on the efficacy and safety of oral antibiotic bowel preparation and mechanical bowel preparations for elective colorectal surgeries.

Areas of strength:

• Improved on my ability on making my slides less text-heavy and busy
• Improved on my ability to organize my presentation in a way that is easier to follow

Areas of improvement:

• Slow down when presenting, especially when highlighting pertinent information
  • Gauge my audience’s body language and assess if more time needs to be spent on a particular slide or piece of information
• Make more eye contact with my audience
• Need to be more familiar with the details of all the trials I list in my presentation

My handout: bowel-prep-case_final

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Reflections – Surgery

The following are my objectives for surgery:

1. Continue to develop a systematic thought process to assessing and managing infectious diseases
2. Continue to develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)
3. Continue to develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides and anticoagulation
4. Develop my ability to effectively manage anti-coagulation (e.g. pre- and post-op management, duration of treatment or prophylaxis)
5. Continue to develop my ability to write concise and clear chart notes

Another great rotation at RCH! Bruce was incredibly knowledgeable and helped to build my thought process regarding patients in surgery. This rotation definitely gave me a lot of experience with infectious diseases, especially intra-abdominal infections. Bruce also helped schedule a shadowing opportunity for me with one of the antimicrobial stewardship pharmacists. One key thing I will always keep in mind when managing infections is the importance of source control! Unfortunately, I was not able to get any experience with aminoglycosides…but was able to get lots of experience with anticoagulation (e.g. VTE prophylaxis for patients who have abdominal surgery for cancer – requires 28 days of LMWH). Generally, VTE prophylaxis is started on POD 1 with dalteparin if eGFR > 10. With Bruce’s guidance, I was able to write clearer chart notes. Writing concise and clear chart notes will definitely be a goal that I will continue in future rotations.

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

Nov 2/2015 (1230hr) Clinical Pharmacy Note

ID: 54 yo male with Fournier Gangrene admitted on Oct 29/16

s/o: Abx:

1. Pip/Taz 3.375mg IV Q6H
2. Vancomycin 1g IV Q12H
   Both started since Oct 29/16

Micro: BCx (Oct 29): -, MRSA swabs (Oct 31): -, Urine Cx (Oct 29): -, Ascitic Fluid (Oct 29): –
No cultures done for debridgement of penis scrotum and perineum

Labs:                     Oct 31                Nov 1                 Nov 2
sCr                          96                       143                     114
eGFR                      77                       48                       63
WBC                       16.9                    19.2                    15.4
Neuts                     12.8                    13.2                    11.8

Vanco trough level: 23.2 mg/L (pre 6th dose at 3S)

A:

1. No cultures to guide need for vancomycin but low risk for MRSA as swabs are negative on Oct 31/16
2. Level is supratherapeutic and at steady state (target: 15-20mg/L). Level drawn and doses given appropriately. Level likely increased due to accumulation caused by AKI
3. Renal fx improved with NS bolus, albumin and holding off diuretics yesterday. Starting midodrine and octreotide today. Renal function will likely be unstable over next few days

P:

1. Decrease vancomycin dose to 750mg IV Q12H (at 100hr and 2300hr)
2. Monitor renal function, CBCs + diffs daily and assess pre-4th 750mg IV dose trough level
3. Suggest: R/A vancomycin as MRSA swabs (-)

Nov 7/2016 (1550hr) Clinical Pharmacy Note

ID: 54 yo male admitted on Oct 29/16 for Fournier Gangrene

s/o: Currently on vancomycin 750mg IV Q12H + Pip/Taz 3.375mg IV Q6H
Vital signs (Nov 7):

Labs:                     Nov 5                Nov 6                 Nov 7
sCr                          97                       98                       64
eGFR                      79                       76                       112
WBC                       8.3                     9.0                      15.0
Neuts                     5.3                      5.6                      10.6

Vancomycin trough level (Nov 7/16): 14.8mg/L (was 17.0mg/L on Nov 4/16)
No new cultures since last level

A:

1. Vancomycin for empiric coverage of Fournier Gangrene until Nov 15/16
2. All doses are given and levels drawn appropriately. Level is at steady state
3. As per nurse, patient is very edematous and urine output is very low. This is reflected by his recent increase in serum creatinine. If patient is volume overloaded, this may also explain his increase in WBC and CBCs.
4. Vancomycin level is slightly subtherapeutic (target: 15-20mg/L). However, there is a risk of accumulation with AKI

P:

1. Continue current dose of vancomycin 750mg IV Q12H
2. Monitor renal function, CBCs and diffs daily
3. Order vancomycin trough level pre-6AM dose on Nov 9

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Order:

• Change vancomycin dose to 750mg IV Q12H. Start dose at 1300hr
  • Pharmacy: please schedule on MAR at 1AM, 1PM
• Vancomycin trough level prior to 1AM dose on Nov 4 (i.e. Pre 4th dose of 750mg IV dose)
• Pharmacy will continue to follow.

For DR___ (ID, per Rx to dose). Pharmacist

Notes:

• If discontinue vancomycin and start new vancomycin order, will be changing stop dates

Asplenia

Background:

Spleen:

• a spongy, soft organ about as big as a person’s fist, is located in the upper left part of the abdomen, just under the rib cage
• made up of two basic types of tissue, each with different functions:
  • White pulp – part of immune system
    • produces WBCs called lymphocytes which in turn produce antibodies
  • Red pulp
    • filters blood, removing unwanted material
    • contains other WBCs called phagocytes that ingest microorganisms (e.g. bacteria, fungi, virus)
    • monitors RBCs and destroys those that are abnormal, old or damage
    • reservoir for different elements of the blood, especially WBCs and platelets
• Able to live without a spleen
  • However… body loses some of its ability to produce protective antibodies and to remove unwanted microorganisms from the blood
    = impaired immune system
  • Particularly at risk of infection by encapsulated bacteria e.g. Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae
• If spleen is injury, may expect PLTs to increase (more crucial to be on VTE Px)

Splenectomy:

• Surgical removal of spleen

Case: KK is a 21 yo female (wt = 72kg, ht = 167 cm) who was diagnosed with a mid-body pancreatic neuroendocrine tumour (>2cm)  had a laparascopic (minimally invasive) distal pancreatectomy and splenectomy

• WBC are elevated post-op since patient no longer has spleen which cleans out WBC
• Received pre-op splenic vaccinations and on October 5: Prevnar 13, Oct 8/9: Tetanus and Meningitis
• Surgery – Oct 14, 2016 (patient did not get dose 14 days pre-op → might not be fully protected by vaccinations on date of surgery)
• T 36.7, RR 12-16, HR 70, O2sats 99% RA
• Pre-op received 1 dose of cefazolin 2g IV

Post-Op Management:

Infection Risk:

I. Antibiotics

Daily prophylaxis:

• Do not recommend routine prophylaxis in asplenic adults

General pre-op prophylaxis (RCH): (against G+ pathogens in skin)

• Administer 60 mins or less prior to skin incision
  • Cefazolin 2g IV
  • Cefazolin 2g IV and metronidazole 500mg IV
• >120kg:
  • Cefazolin 3g IV
  • Cefazolin 3g IV and metronidazole 500mg IV
• Significant penicillin/cephalosporin allergy:
  • clindamycin 900mg IV
  • metronidazole 500mg IV
  • gentamicin (5mg/kg, round to closest 20mg) mg IV
    • If body weight is 20% above IBW, gentamicin dose should be adjusted.
  • Ciprofloxacin 400mg IV. If renal dysfunction precludes use of genatmicin
• For patients with known MRSA colonization:
  • Vancomycin (15mg/kg IV, round to closest 250mg IV).

II. Vaccinations recommendations for adults with anatomical or functional asplenia:
Risk for overwhelming postsplenectomy sepsis (0.05% to 2% incidence in splenectomy – source: http://www.surgicalcriticalcare.net/Guidelines/splenectomy_vaccines.pdf)

• Recommended Adult Immunization Schedule 2016 (USA):
  • http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf
  • Hib vaccination
    • 0.5 mL IM x 1 dose
  • Pneumonia vaccination
    • PCV 13 0.5 mL IM x 1 dose – 8 weeks after → PPSV 23 0.5mL IM x 1 dose
    • PPSV 23 0.5mL IM x 1 dose 5 years after 1st dose of PPSV 23
  • Meningitis vaccination
    • Administer 2 doses of MenACWY (Meningococcal conjugate 0.5 mL IM) at least 2 months apart
      • Revaccinate every 5 years
    • Administer a series of MenB vaccine.
• BC Centre for Disease Control:
  • http://www.immunizebc.ca/infographic/story.html
  • http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%202%20-%20Imms/SectionIII_ImmunizationofSpecialPopulations.pdf
  • Hib vaccination:
    • Asplenic clients > 5 years of age who should receive one dose of Hib vaccine regardless of their immunization history.
  • Pneumonia vaccination:
    • Pneumococcal conjugate and/or polysaccharide vaccine
    • Requires once only revaccination with polysaccharide vaccine
  • Meningitis vaccination:
    • Meningococcal quadrivalent conjugate vaccine
  • Flu vaccine yearly
  • Recommend inactivated vaccines

Recommendations:

Vaccines can either be started 14 days pre-op or 14 days post-op

Pneumonia:

• 13-valent Pneumonia Conjugate Vaccine (PCV13) 0.5mL IM x 1 d0se
• 23-valent Pneumonia Polysaccharide Vaccine (PPSV23) 0.5mL IM x 1 dose
  • 8 weeks after PCV13
• Repeat vaccinations every 5 years

Meningitis:

• Meningococcal quadrivalent conjugate vaccine 0.5mL IM x 1 dose
• Repeat above dose 2 months after 1st dose
• Repeat vaccinations every 5 years

Influenza vaccine

• Repeat inactivated influenza vaccine annually

H. influenzae type B vaccine

• H. influenzae type B vaccine 0.5 mL IM x 1 dose

Anti-coagulation:

General pre-op VTE prophylaxis (RCH):

• Minor surgery procedures: Heparin 5000 units SC 60-90 mins pre-op
• Major surgery procedures prophylaxis to be given in OR by anesthesiology after consideration of epidural

General post-op VTE prophylaxis (RCH):

• All patients requiring major surgical procedures → moderate or high risk
• Give 1st post-op dose:
  • Heparin 5000 units SC one dose evening at surgery (POD 0), then on POD 1 change to dalteparin 5000 units SC once daily in morning until discharged
  • For patients with severe renal impairment, heparin 5000 units SC Q12H starting evening of surgery, continue until discharged. CBC on POD 1, 2 and 3

VTE prophylaxis (treat with LMWH):

• Generally 10-14 days
• Pelvic or abdominal surgery → 4 weeks
  • High risk, as per special authority:
    • previous hx of VTE
    • anaesthesia time > 2 hrs
    • bed rest > 4 days

Case Recommendations:

• After Dec 3, get:
  PPSV 23, Hib, Meningitis Conjugate, Influenza x 1 dose
• Dalteparin 5000 units SC daily until Nov 12, 2016 (inclusive)

References:

• LMH Reference: splenectomy_vaccines
• https://www.merckmanuals.com/home/blood-disorders/spleen-disorders/overview-of-the-spleen

Surgery – Objectives

I will be starting my surgery rotation tomorrow at Royal Columbian Hospital. The following are my rotation-specific objectives:

1. Continue to develop a systematic thought process to assessing and managing infectious diseases
2. Continue to develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)
3. Continue to develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides and anticoagulation
4. Develop my ability to effectively manage anti-coagulation (e.g. pre- and post-op management, duration of treatment or prophylaxis)
5. Continue to develop my ability to write concise and clear chart notes

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Other things I would like to accomplish if possible:

• Systematically and effectively work up patients within 2 hours
• Observe how the nurses administer dalteparin syringes
• Gain a better understanding on total parenteral nutrition
• Observe one surgery
• Procedure Logs:
  • C3.2 R5: Perform and document a “Best Possible Medication History (BPMH)”
  • C3.5 R2: Prepare and deliver educational seminar to nurses, physicians or other allied health care members
  • C3.5 R2: Prepare and deliver educational seminar to pharmacists