The Washington Manual Internship Survival Guide (12 page)

•
  What follows is adapted from the Barnes Jewish Hospital Stem Cell Transplant Unit Febrile Neutropenia Pathway.
The recommendations are based on antibiotic resistance patterns specific to Barnes Jewish Hospital. Consult your hospital’s antibiogram to tailor antimicrobial therapy to local resistance patterns.

•
  Definition of neutropenic fever: Temperature >38.3°C, or ≥38.0°C for at least 1 hour, with ANC ≤500 or anticipate ANC to fall <500.

•
  Workup: Obtain blood cultures × 2, physical exam, CXR, UA, and culture.

•
  
Initial treatment
:

•  
Cefepime
1 g IV q8h.
If PCN allergy: ciprofloxacin 400 mg IV q12h or aztreonam 2 g IV q8h.

•  
Vancomycin
1 g IV q12h if any of the following are present: Severe mucositis, clinical evidence of catheter-related infection, known colonization with resistant
Streptococcus
or
Staphylococcus
, sudden temperature spike > 40°C, hypotension, or sepsis.

•  Consider
metronidazole
500 mg IV q8h, if suspected oropharyngeal or intra-abdominal source.

•  Consider addition of
gentamicin
5 mg/kg IV q24h × 72 hours, if clinically unstable.

•  Tailor antibiotics based on culture results.

•
  
Treatment of persistent fevers
: new fever after afebrile ≥48 hours or persistently febrile ≥72 hours and cultures negative.

•  If clinically unstable: change GNR coverage to
meropenem
500 mg IV q6h or
ciprofloxacin
400 mg IV q12h ±
aminoglycoside.

•  If clinically stable: continue current regimen and tailor based on culture results.

•  If persistently febrile >5 days and cultures negative:

▪  If the patient is NOT on anti-mold prophylaxis and NO identified clinical sites suspicious for fungal infection: use
echinocandin
.

▪  If the patient is NOT on anti-mold prophylaxis and clinical site suspicious for fungal infection (excluding sinusitis, see below): use
voriconazole
, weight-based dosing for IV and PO administration.

▪  If the patient is on anti-mold prophylaxis and NO identified clinical sites suspicious for fungal infection:

▪  Clinically stable: no change in antifungals, monitor closely.

▪  Clinically unstable:
amphotericin B lipid complex
(ABLC) 5 mg/kg IV qday. If already receiving amphotericin product, obtain an ID consult for antifungal selection.

•  If the patient is on anti-mold prophylaxis and clinical site suspicious for fungal infection: Use ABLC 5 mg/kg IV qday.

•  If the patient has suspected fungal sinusitis: ABLC 5 mg/kg IV qday.

•
  
Duration of antibiotics
:

•  Discontinue vancomycin after 72 hours if cultures are negative for coagulase-negative staphylococci, oxacillin-resistant
Staphylococcus aureus
, cephalosporin-resistant streptococci, or
Corynebacterium jeikeium
.

•  Discontinue double GNR coverage (e.g., aminoglycoside) after 72 hours if cultures are negative for GNR and the patient is clinically stable.

•  Culture negative for 3 to 5 days:

▪  Afebrile and ANC ≥500, discontinue after 48 hours.

▪  Afebrile and ANC 500, continue antibiotics until ANC ≥500 for 48 hours.

▪  Febrile and ANC ≥500, reassess after 4 to 5 days.

▪  Febrile and ANC <500, continue antibiotics until neutropenia resolves.

•  Culture positive:

▪  Remove line if
Pseudomonas
spp.,
Stenotrophomonas maltophilia
,
Acinetobacter
spp., vancomycin-resistant enterococcus,
S. aureus
,
C. jeikeium
, and
Candida
spp.

▪  All other organisms and tunnel catheter infections, consider removing line.

▪  Continue antibiotics until ANC ≥500 for 7 days or for 14 days total, whichever is longer.

•  UTI: Continue antibiotics until ANC is ≥500.

•  Pneumonia:

▪  Bacterial: Until ANC ≥500 × 7 days or for 14 days total, whichever is longer.

▪  
Aspergillus
spp. (suspected or proven): Voriconazole (weight-based dosing) and consider ID consult.

SHORTNESS OF BREATH

•
  What are the patient’s vital signs, including temperature? When was the onset of SOB and what was the reason for admission? Does the patient have reactive airway disease or COPD? Is the patient getting oxygen?

•
  Order oxygen and an ABG kit to the bedside.
Patients with SOB need to be seen immediately.

Major Causes of Shortness of Breath

•
  Pulmonary: Asthma, COPD, pulmonary embolism, pneumonia

•
  Cardiovascular: CHF, MI/ischemia, cardiac tamponade

•
  Others: Pneumothorax, obstruction (e.g., mucous plug), anxiety

Things You Don’t Want to Miss (Call Your Resident)

•
  Inadequate tissue oxygenation (i.e., hypoxia)

•
  Tension pneumothorax

•
  Airway obstruction

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart. Get an ECG, ABG, and CXR if the patient looks sick.

Focused Examination

•
  General: Does the patient appear ill or distressed?

•
  Vitals: Repeat now. Check for pulsus paradoxus.

•
  Cardiovascular: Heart rate, JVP, skin temperature and color, capillary refill.

•
  Lungs: Listen for crackles and breath sounds on both sides, evidence of consolidation or effusion.

•
  Neurologic: Mentation

Laboratory Data

•
  Consider ABG, ECG, troponins, CBC, D-dimer, V/Q scan, and CXR.

•
  If you have any doubt at all, get an ABG—if you think about it you should do it. Beware of relying on pulse oximetry alone.

Management

•
  Order empiric oxygen to keep saturations >92%. Be cautious if the patient has COPD and is a retainer of CO
₂
—in that case, keep O
₂
saturations around 88% to 90% and check ABG.
Remember that the O
₂
saturation tells you nothing about pH or PCO
₂
.

•
  For asthma or COPD, administer albuterol and ipratropium by nebulizer, q2-4h until stable. Consider IV corticosteroids, methylprednisolone, 60 mg IV q6h, and antibiotics if needed.

•
  For CHF, is the patient volume overloaded? Raise the head of the patient’s bed. Administer furosemide, 20 to 40 mg IV, and albuterol nebulizer. Consider morphine or nitroglycerin. Assess for adequate diuresis.

•
  For suspected cardiac tamponade, order a stat cardiac echo and cardiology consult.

•
  For pulmonary embolism, often the patient is tachycardic and tachypneic and has a sudden onset of SOB. The classic, though not usually present, ECG findings are S1, Q3, and T3 (S waves in lead I, Q waves in lead III, inverted T waves in lead III). If suspicion is high, consider starting heparin or LMWH. Ensure that the patient has no history of bleeding disorders, PUD, recent CVA, or surgery. Obtain CT pulmonary angiography or a V/Q scan.

•
  Acute respiratory failure is generally defined by ABG of PO
₂
< 60 or PCO
₂
>50 with a pH <7.3 while on room air. Ensure that the patient hasn’t received narcotics recently. If so, consider naloxone, 0.2 mg IV. Acute respiratory acidosis with a pH <7.2 usually requires mechanical ventilation.

GASTROINTESTINAL BLEEDING

•
  What are the patient’s vital signs? When was the onset of bleeding and what is the reason for admission? Is the bleeding upper (coffee ground emesis, melena) or lower (hematochezia)? How much blood has been lost?

•
  Confirm that the patient has IV access (at least 18G) and recent CBC and INR. Type and cross-match blood.
If the patient is tachycardic or hypotensive, see the patient immediately.

Major Causes of Gastrointestinal Bleeding

•
  Upper: Esophageal varices, Mallory-Weiss tear, peptic ulcer, esophagitis, neoplasm, aortoenteric fistula (history of AAA repair).

•
  Lower: Diverticulosis, angiodysplasia, neoplasm, IBD, infectious colitis, anorectal disease (hemorrhoids, fissures).

Things You Don’t Want to Miss (Call Your Resident)

GI bleeding leading to hypovolemic shock

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature. Orthostatic BP.

•
  Quickly look at the patient and review the chart.

Focused Examination

•
  General: How distressed or sick does the patient look?

•
  Vitals: Repeat now.

•
  HEENT: Check for conjunctival pallor or scleral icterus.

•
  Cardiovascular: Heart rate, JVP, skin temperature and color, capillary refill.

•
  Abdomen: Check for tenderness and bowel sounds, look for ascites.

•
  Rectal: Must be performed. Guaiac stool.

•
  Neurologic: Evaluate level of consciousness and ability to protect airway.

Laboratory Data

•
  Consider CBC, coags, and CMP.

•
  The initial CBC may be deceptive in acute GI bleeding.

Management

•
  Insert two large-bore IVs (16G to 18G), type and cross pRBCs. It can take up to 8 hours for CBC to equilibrate, so initial Hct may falsely appear normal or unchanged. In the absence of renal disease, high BUN suggests GI bleeding. Check coags and platelets to exclude bleeding disorders. Is the patient receiving anticoagulants? If so, stop the anticoagulant and consider reversal with FFP or vitamin K.

•
  Consider whether special blood products are required based on comorbidities (e.g., irradiated or washed RBCs). Also consider whether the patient needs premedication with acetaminophen/diphenhydramine based on prior transfusions.

•
  Bolster the intravascular volume by giving IV fluids (normal saline), especially while awaiting blood products. Keep the patient NPO.

•
  For upper GI bleeding, insert a nasogastric tube and perform lavage to assess if active bleeding is present. Suppress acid with PO (or IV) proton pump inhibitor therapy. GI consult for endoscopy. If bleeding has stopped and the patient is hemodynamically stable, elective endoscopy can be performed within the next 24 hours. Otherwise, urgent endoscopy may be required for diagnosis and treatment.

•
  For active variceal bleeding in patients with cirrhosis, start IV octreotide (somatostatin), 50 μg bolus, then 50 μg/h, start prophylactic IV ceftriaxone 1 g/day, correct coagulation deficits, replace pRBCs as needed. Call a GI consult as urgent endoscopy may be required.

•
  For lower GI bleeding, correct fluid status. If hemodynamically stable, obtain GI consult for colonoscopy. If unstable, an urgent tagged RBC scan should be scheduled. Also, consider arteriography.

•
  Surgery consult/indications include the following:

•  Aortoenteric fistula

•  Uncontrollable or recurrent bleeding

•  Bleeding episode requiring transfusion of more than 6 units pRBCs

•  Visible naked vessel seen in peptic ulcer by endoscopy

Pain Control

16

GENERAL PRINCIPLES

•
  
Pain
is defined as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage.”

•
  Many complex biopsychosocial factors influence the outward manifestations of pain, both acute and chronic. As a result, pain assessment is subjective; there is no such thing as an objective “pain-o-meter.” We must rely on patient description.

•
  In the hospital, pain rating scales (e.g., “1 to 10 pain scale” or the “Wong-Baker FACES Pain Rating Scale”) are frequently used to standardize these descriptions. Pain rating scales have poor inter-rater reliability but good intra-rater reliability, so they may be helpful for tracking changes in a patient’s pain.

•
  The pain management strategy should be appropriate to the degree of pain (
Table 16-1
) and should be put into place concurrently with attempts to diagnose and treat the source of the pain.