Tuesday, December 27, 2016

WILTIMS #512-3: Dosing, ordering, staging and grading

Thursday: Don't underdose pain meds in children. We have a tendency to look at kids as being small and feeble and are reticent to giving then the full dose of pain medications, even after adjusting the dose for their weight. But that's just silly! We wouldn't give them less antibiotics than recommended just because they're small and cute, so why would we make them suffer when it's perfectly safe to give them proper pain coverage? It happens all the time though, so we have to be vigilant and follow the evidence.

ThursdayIL: The enzyme asparaginase, which is used as an adjunct cancer therapy, can be produced both in E. coli, our typical enzyme-mass-producing organism of choice, and Erwinia chrysanthemi (recently renamed as Dickeya dadantii), a bacterium otherwise only known as an infectious agent to plants. If a patient is allergic to the E. coli variety, they get asparaginase-Erwinia.

Friday: It's frustrating not being able to put in orders as a sub-I. Of course, it makes sense legally and for patient safety. But as we are the pseudo-doctors in charge of our patients, when a nurse needs something for a patient, they page us, not the other residents who can actually write orders. So it ends up happening with frustrating frequency that we have a plan in place for some banal anticipated event that is delayed because I need to get an actual resident to switch away from whatever they are doing to open up my patient on the EMR (electronic medical record) to sign off on my orders. It seems like such a simple task, but since everyone else is usually taking care of sicker patients, my requests almost never take priority. Again, this is how it needs to be for many reasons, but that doesn't mean it's not frustrating.

FridayIL: The staging and grading of acute graft-vs-host disease (GVHD) is pretty complicated. Each involved organ system has four stages of involvement and then the grade is determined by either of two different systems that weigh the combinations of staging of each organ system. For example, both systems only allow for skin involvement in the lowest grade of the disease; even stage 1 involvement of the liver or gut automatically raises the grading. But if you have stage 4 involvement of any organ, then you are automatically grade 4.

I also learned a nice rule of thumb for pRBC (packed red blood cells) transfusion in severe iron deficiency anemia. You don't want to overload the heart and cause heart failure, so only transfuse at a rate less than or equal to the hemoglobin level (e.g. ≤4ml/kg/hr for a Hg of 4g/dL).

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