The Pharm So Hard Podcast: An Emergency Medicine and Hospital Pharmacy Podcast

The Pharm So Hard Podcast: An Emergency Medicine and Hospital Pharmacy Podcast

By Jimmy Pruitt & Oscar SantaloMedicineHealth & Fitness
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The Pharm So Hard Podcast: An Emergency Medicine and Hospital Pharmacy Podcast episodes

  • Episode 75. Alteplase vs Tenecteplase for Ischemic Stroke by Jim Priano
    Friday-0400-Jim-Priano-Alteplase-vs-TenecteplaseDownload
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    The post Episode 75. Alteplase vs Tenecteplase for Ischemic Stroke by Jim Priano appeared first on The Pharm So Hard Podcast.

    44 min
  • Episode 74. Peeing in the wind: The Management of UTI in the ED

    Urinary tract Infections

    Epidemiology

    In the United States, urinary tract infection is the most common bacterial infection. It has about more than 8 million visits yearly. UTI is more common in women in which 50% will experience it in their lifetime. Women are 6 times more affected than men. Antibiotic is its main treatment. 15% of medicines are made for UTI.

    Classifications of UTI:

    • Complicated – urinary tract infections are related with a predisposing lesion of the urinary tract; however, this may also refer to all other infections, excluding those in the health, premenopausal adult female.
    • Uncomplicated – is an infection in a healthy, premenopausal female who lacks anatomical or functional deviations of the urinary tract. About 75%-90% of most uncomplicated UTIs are due to Escherichia coli and the rest are due to Staphylococcus saprophyticus, Proteus spp., and Klebsiella spp.

      • Recurrent UTI are either:

      • Reinfection – occurs more than 2 weeks after the last UTI and recognized as new uncomplicated UTI.
      • Relapse – occurs within 2 weeks of the original infection, and it is considered as a relapse of the original infection. This may be due to unsuccessful treatment of the original infection, structural deviations, or resistant microorganisms.

        • Etiology

        Lower UTI or refer as cystitis is more common in women than in men. The upper UTI is also refer to as pyelonephritis. The common cause of UTI is different bacteria which is specified below:

        Complicated UTI may be caused by the following organisms:

        • Gram-negative organisms and
        • Enterococcus faecalis

          • Uncomplicated UTI may be caused by the following organisms:

          • Escherichia coli
          • Staphylococcus saprophyticus
          • Proteus spp.
          • Klebsiella spp.

            • Pathophysiology 

            Clinical Presentation

            Types of UTI
            Signs and Symptoms
            Lower UTI
            Dysuria
            Urgency
            Frequency
            Nocturia
            Suprapubic heaviness  
            Upper UTI  
            Fever
            Nausea
            Vomiting
            Flank pain  

            Risk Factors

            UTI also comes with different predisposing factors such as the following:

            PATIENT
            RISK FACTORS
            Premenopausal women of any age
            ·         Diabetes
            ·         Diaphragm use, especially those with spermicide
            ·         History of UTI or UTI during childhood
            ·         Mother or female relatives with history of UTIs
            ·         Sexual intercourse
            Postmenopausal and older adult women
            ·         Estrogen deficiency
            ·         Functional or mental impairment
            ·         History of UTI before menopause
            ·         Urinary catheterization
            ·         Urinary incontinence
            Men and women with structural abnormalities
            ·         Extrarenal obstruction associated with congenital anomalies of the ureter or urethra, calculi, extrinsic ureteral compression, or benign prostate hypertrophy
            ·         Intrarenal obstruction associated with nephrocalcinosis, uric acid nephropathy, polycystic kidney disease, hypokalemic or analgesic nephropathy, renal lesions from sickle cell disease

            Diagnostics

            Laboratory Tests
            Implications
             Urine Analysis  
            is often used to determine UTIs, and a clean-catch dipstick leukocyte esterase test is a rapid screening test for detecting pyuria with a high sensitivity and specificity for detecting more than 10 WBC/mm3 in urine (Sobel 2014).
            Urine Culture
            is not suggested for treating acute uncomplicated cystitis. However, for acute pyelonephritis and any type of complicated UTIs, a urine culture should be conducted before empirical therapy to maximize the subsequent specific antibiotic therapy once the susceptible results are obtained.
            Basic metabolic panel  
            A basic metabolic panel is a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, and kidney function. Glucose is a type of sugar your body uses for energy. Electrolytes keep your body’s fluids in balance.
            Complete blood count  
            For upper urinary tract infection, CBC is required by most physician to determine if the infection has not spread to your blood stream.

            Treatment

            Category
            Probable Organisms
            Regimen
            Duration of Therapy

            Asymptomatic bacteriuria   Positive culture ≥ 100,000 cfu/ml with or without pyuria but without signs and symptoms
             
            This should be treated in pregnant patients. Those who are undergoing urologic procedure in which mucosal bleeding may occur. Neutropenic

            o   Uncomplicated o   Cystitis   Signs or symptoms (frequency, urgency, dysuria, suprapubic pain) PLUS pyuria (>10 WBC/hpf) PLUS positive urine culture ≥ 100,000 Uncomplicated = non-pregnant females, no urologic abnormalities, no stones, no catheter
            E. coli
            1st Line therapy • Nitrofurantoin monohydrate/macrocrystals 100 mg BID x 5 days OR • Trimethoprim-sulfamethoxazole 160/800 mg 1 tablet BID x 3 days (avoid if local resistance > 20%) OR • Fosfomycin trometamol 3-gram single dose   2nd Line therapy • Fluoroquinolones: ciprofloxacin 250 mg BID x 3 days, levofloxacin 250 mg daily x 3 days OR • Guidelines and FDA recommend reserving for other uses than acute uncomplicated cystitis   Beta-lactams (e.g., amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime) 3-7 days of treatment • Studies have shown beta-lactams to be less effective than TMP-SMX or fluoroquinolones
            o   Uncomplicated o  Pyelonephritis
            E. coli
            Pyelonephritis (Discharging home from ED) – First Line therapy • Fluoroquinolones – Ciprofloxacin 500 mg BID x 7 days – Levofloxacin 750 mg daily x 5 days • TMP-SMX 1 tablet BID x 14 days • Beta-Lactams – Amoxicillin-clavulanate 875/125 mg 1 tablet BID x 14 days – Cefpodoxime 200 mg BID x 14 days • Dosing also dependent upon renal function
            Complicated Signs or symptoms (frequency, urgency, dysuria, suprapubic pain) PLUS pyuria (>10 WBC/hpf) PLUS positive urine culture ≥ 100,000 Complicated = male, possible stones, urologic abnormalities, neurogenic bladder * Gonorrhea and Chlamydia should be suspected in a sexually active male with a UTI (refer to Grady STD Guidelines for treatment options)
            E. coli
            First Line: Cefuroxime 500 mg PO q12h   Second Line: Ciprofloxacin 500 mg PO q12h
            7 days

            ·         Urinary Tract Infection in Men ·         Prostatitis  
            E. coli, but the spectrum of pathogens is more variable for CBP, including E. coli, E. faecalis, K. pneumoniae, P. mirabilis, P. aeruginosa, S. aureus, and streptococcal spp. (Grabe 2015).  
            The presence of fever with symptoms of cystitis in men may indicate acute bacterial prostatitis (ABP).   When symptoms persist for more than 3 months, chronic bacterial prostatitis (CBP) occurs. Most men with CBP have a condition called chronic pelvic pain syndrome. Four main symptoms of CBP and chronic pelvic pain syndrome are urogenital pain, lower urinary tract symptoms including voiding or storage symptoms, psychological issues, and sexual dysfunction (Rees 2015).
            7 days
            ·         Urinary Tract Infection in Pregnancy  
              E. coli
            Pregnant women should have the treatment for UTI even if they asymptomatic   • Urine culture with ≥ 105 CFU/mL (≥ 104 CFU/mL if group B Streptococcus)   -Outpatient therapy • Nitrofurantoin (Class B) • Beta-Lactams (Class B) -Inpatient therapy • Ceftriaxone (Class B) • Cefepime (Class B) – reserve for history of previous resistance • Piperacillin-Tazobactam (Class B) – reserve for history of previous resistance
            5 Days
            ·         Catheterized Patients   Patients with urinary catheter is prone to acquire bacteria that may lead to UTI.  
            Proteus spp., M. morganii, and P. stuartii
            Individuals symptomatic with CA-UTI are treated similarly to those with acute complicated cystitis in the absence of upper tract symptoms or complicated pyelonephritis if upper tract symptoms are present (Sobel 2014) A urine culture should be obtained before initiation of antibiotic therapy, if possible, from a newly placed catheter because the bacterial less useful (Hooton 2010). In addition, an indwelling catheter that has been in place for 7 days or longer should be removed or replaced before initiating antibiotics (Grabe 2015).
            5-7 days

            The post Episode 74. Peeing in the wind: The Management of UTI in the ED appeared first on The Pharm So Hard Podcast.

            41 min
          • Episode 72. Its all in your head! Management of Headaches in the ED

            Migraine is a common episodic disorder, the hallmark of which is a disabling headache generally associated with nausea and/or light and sound sensitivity

            For moderate to severe migraine attacks not associated with vomiting or severe nausea, oral migraine-specific agents are first-line, including oral triptans

             Patients who present with migraine in emergency settings generally have unusually severe attacks, and in many cases, their customary acute migraine treatment has failed to provide relief 

            Related FOAM Posts

            https://www.nuemblog.com/blog/2018/4/26/headache

            emDocs Cases: Headache Management in the ED

            Managing migraine headaches in complicated patients

            https://www.emra.org/books/pain-management/migraine/

            https://www.tamingthesru.com/blog/mastering-minor-care/management-of-migraines

            The post Episode 72. Its all in your head! Management of Headaches in the ED appeared first on The Pharm So Hard Podcast.

            17 min
          • Episode 71. Pushing P! Phenobarbital for Alcohol Withdrawal Syndrome

            Alcohol withdrawal syndrome (AWS) is a disease commonly treated in the emergency department, with
            ~5% of cases leading to delirium tremens.

            1. In patients with a history of AWS, decreased GABA-A receptor sensitivity to GABA agonists may cause
              benzodiazepine (BZD) monotherapy to be ineffective.
            2. Patients may experience increase in morbidity and mortality due to escalated doses of benzodiazepines.
            3. There are likely a subset of patients that respond poorly to benzodiazepines, therefore requiring alternative
              mechanisms to treat AWS.
            4. Phenobarbital (PB) has some theoretical benefits over benzodiazepines alone from a mechanistic
              perspective.
              a. Chronic alcohol use leads to down regulation of GABA-A receptors and up-regulation of NMDA
              receptors.
              b. Abrupt withdrawal of alcohol use leads to greater NMDA receptor-mediated excitatory activity,
              which may be inhibited more effectively with phenobarbital rather than benzodiazepines.
            PharmacologyDosePrior to benzodiazepines 5-10 mg/kg over 30 minutes Can split up into multiple doses if concerned about respiratory depression   After receiving benzodiazepines •          130-260 mg PRN Q30 minutes to clinical effect(Max ~10-15 mg/kg)Mechanism of ActionBind to the GABA receptor at a different binding site than BZDs, increasing the time the GABA-mediated chloride channels remain open. •          inhibitor of excitatory AMPA glutamates receptorsFormulationsIV/IM/PO           PK/PDOnset: IV ~5 minutes Duration:  6-12 hours Half-life:  80-120 hours      Renal Excretions: 21% Therapeutic Blood levels: 15-40 ug/mL           Adverse EffectsHypotension, respiratory depression, ataxia, lethargyDrug Interactions and warningsWarning with loading doses in patient that are hypotensive and received large doses of benzodiazepinesCompatibilityCompatible with NS, D5W, and LR  
            Overview of EvidenceAuthor, yearDesign/ sample sizeIntervention & ComparisonOutcomeIbarra, 2019Retrospective observational/ n=78Lorazepam protocol  only (LZP)   PB x 1 + LZP protocol  (PB+LZP)No difference in daily lorazepam requirements or hospital LOS   PB+LZP group had ↑ pts d/c within 72 hrs   No patient in PB group experience intubation or hypotensionNisavic, 2019Retrospective observational/ n=562BZD only fixed dosing   PB- Based Protocol (IM load + PO taper)No difference in AWS-related seizures , ICU admission, over-sedation, LOS, and hallucinations   ↑ Delirium in BZP group   In BZPàPB crossover pts, PB led to rapid improvement of BZP resistant AWS symptomsNelson, 2019Pre-post observational/ n=300IV diazepam alone (DZP)   IV LZP + IV PB (LZP + PB)   IV PB alone (PB)No difference in ICU admission, ICU LOS, and need for intubation.   PB associated with ↑ ED LOS but ↓ BZP requirementsTidwell, 2019Pre-post observational/ n=120BZD only CiWA- Protocol   PB Taper ± Benzo PRNPB ↓ ICU+ Hospital LOS   PB↓ total lorazepam requirements   PB had less patient intubatedSullivan, 2018Retrospective observational/ n=209BZD only CIWA- Protocol   PB + BZD CIWA ProtocolNo difference in ICU admission, intubation, hypotension, ED LOS, CIWA score at ED discharge   PB group had ↓hospital LOS and Max CIWA score at 24 hrsRosenson, 2013RCT/ n=102PB 10 mg/kg IV x1 + PRN benzodiazepines   Placebo + PRN benzodiazepinesPB had ↓ ICU admission   PB had ↓continuous infusion lorazepam   PB had ↓ total lorazepam requirements   No difference in ICU or hospital LOS

            References

            1. Phenobarbital. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 28, 2019, from http://www.micromedexsolutions.com/
            2. Sullivan SM et al. Am J Emerg Med. 2019 Jul;37(7):1313-1316.
            3. Rosenson J et al. J Emerg Med 2013;44:592–8 [e2].
            4. Nisavic M et al. Psychosomatics. 2019 Sep – Oct;60(5):458-467.
            5. Ibarra F Jr et al. Am J Emerg Med. 2019 Jan 30. pii: S0735-6757(19)30075-0
            6. Nelson AC et al. Am J Emerg Med. 2019 Apr;37(4):733-736.
            7. Tidwell WP et al. Am J Crit Care. 2018 Nov;27(6):454-460
            Related FOAM Posts
            PulmCrit- Phenobarbital monotherapy for alcohol withdrawal: Reloaded
            Alcohol withdrawal

            ToxCard: Phenobarbital for Alcohol Withdrawal

            Click to access 60246d68e6cdef7ae9f99bca_Phenobarbital-for-EtOH-Withdrawal-2.0-pharmacy-friday-jlp2.-KRW1.pdf

            The post Episode 71. Pushing P! Phenobarbital for Alcohol Withdrawal Syndrome appeared first on The Pharm So Hard Podcast.

            45 min
          • Episode 69. Ditching the 9 to 5: Overnight Clinical Pharmacy Positions

            https://www.google.com/search?q=overnight+clinical+pharmacy&rlz=1C1GCEB_enUS930US930&oq=overnight+clinical+pharmacy+&aqs=chrome..69i57j69i61.6280j0j4&sourceid=chrome&ie=UTF-8

            https://www.indeed.com/q-Overnight-Clinical-Pharmacist-jobs.html?vjk=f3b3aac7f63ea61a

            https://www.tldrpharmacy.com/content/how-to-survive-your-first-overnight-pharmacist-shifts

            Tips for overnight hospital pharmacist? from pharmacy

            The post Episode 69. Ditching the 9 to 5: Overnight Clinical Pharmacy Positions appeared first on The Pharm So Hard Podcast.

            1 hr 1 min
          • Epsiode 68. Disparities in Healthcare with Juvarez Ogbuneke, MD
            Resources to review
            Disparities in Health and Health Care: 5 Key Questions and Answers

            https://www.ahrq.gov/topics/disparities.html

            https://www.cdc.gov/healthyyouth/disparities/index.htm

            https://www.ajmc.com/view/5-things-about-medical-mistrust

            https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans

            The post Epsiode 68. Disparities in Healthcare with Juvarez Ogbuneke, MD appeared first on The Pharm So Hard Podcast.

            43 min

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          An Emergency Medicine and Hospital Pharmacy Podcast