Haley Gill's ePortfolio

Nephrology – week 3 & 4

haleygill — Thu, 10 Jun 2010 22:37:55 +0000

I’ve been pretty independent on my last few weeks of nephrology. I have been working on the inpatient nephrology ward and rounding with the team on my own. I think it’s been good for me to have to make decisions on the spot and really take things into my own hands as I will soon be on my own (scary!)!

Some of the interventions I have made:

I’ve had 2 HD pts come in with bacteremia. They were ordered the correct antibiotics but were not ordered abx lock solutions for their HD catheters. I ordered the appropriate abx lock solutions for these patients and suggested doing ECHO’s on them as they both have significant cardiac history and could be at risk of endocarditis.

I’ve been adjusting lots of insulin doses and a few blood pressure medications.

We had a patient come in from MSJ for a renal biopsy. The pt has had a recent PE and was anticoagulated with warfarin. His warfarin was stopped b/c of the pending biopsy and he was to be anticoagulated with dalteparin in the mean time and then held 24 hrs before biopsy. In total he would have gotten about 3 or 4 days of dalteparin and LMWH’s accumulate in pts with renal dysfunction so I suggested changing the pt to a heparin infusion and stopping about 6-8hr prior to biopsy. The infusion was started today. UFH infusions do not require adjustment in renal dysfunction. For LMWH’s tinzaparin is thought to have the least accumulation but in general you don’t want to give any of them for prolonged periods of time if the pt has renal failure.

Commitment to the Profession

haleygill — Sun, 06 Jun 2010 02:54:14 +0000

To me commitment to the pharmacy profession means always learning, teaching and working to better the profession of pharmacy. I must continue to be a self directed learner in order to move forward in my pharmacy practice and be able to teach and mentor other new pharmacists, students, residents, etc. It is advocating for what pharmacists do and supporting our professional events and organizations. As pharmacists we must work together and support each other in our individual practices and most importantly learn from each other.

Nephrology – Warfarin in HD

haleygill — Thu, 27 May 2010 23:05:21 +0000

There is a high incidence of AF in HD patients. Depending on CHADS2 score, some of these patients need warfarin therapy. One must be cautious though as ESRD HD patients are already at an increased risk of stroke and bleeding compared to the general population.

Interestingly, warfarin can reduce the function of endogenous vitamin K dependent inhibitors of calcification which can facilitate vascular calcification = bad side effect in HD patients who are already at risk of this!

In normal population steady state with warfarin is reached in about 5 days. In HD patients steady state may take longer possibly up to about 7 or 10 days.

HD patients are also very sensitive to warfarin and often require lower doses than the general population. Diligent INR monitoring is required.

Heparin can interfere with the INR assay so if an INR is drawn after the start of dialysis and pt has gotten heparin must ask the lab to extract the heparin from the sample.

Nephrology – week 1

haleygill — Tue, 25 May 2010 17:30:32 +0000

I spent the first week of my nephrology rotation in the kidney function clinic which is a multidisciplinary outpatient clinic at SPH. The aim of the clinic is to delay the progression of the patients CKD and prepare the patient for dialysis. I enjoyed my time in the clinic and I really like working in an outpatient setting. CKD patients are on a lot of different medications and the pharmacist has an important role!

In addition to seeing patients at the clinic I also reviewed some blood glucose readings sent in by a patient and recommended an increase in his gliclazide. His metformin had to be stopped due to his kidney function so he is now being managed on gliclazide.

I also followed up with a patient who called one of the nurses after taking tramacet and tylenol 3 for pain. He was feeling out of sorts and thought it might be due to tramacet. After speaking with the patient it was unclear as to whether or not he was having any adverse effects of tramacet but he was not having pain so I recommended that he hold off on tramacet for now until he sees his family doctor.

Nephrology – Objectives

haleygill — Mon, 17 May 2010 22:04:11 +0000

I started my last residency rotation (nephrology) today. Time goes by too fast. I don’t know how it’s possible that this residency year is almost over!

My objectives for Nephrology:
1. Become more familiar with drug dosing in the many different stages of CKD.
2. Better understand renal bone dx & anemia
3. Familiarize myself with the nephrology literature

Admin Shadowing

haleygill — Wed, 12 May 2010 05:01:12 +0000

I am completing my administration shadowing with Keith McDonald at Richmond Hospital this week. Yesterday we went to a few different meetings. One meeting was focused on Med Rec and the team was working out the kinks with the Med Rec forms that are available to physicians on pharmanet. The next meeting was with a group from the different long term care facilities across the lower mainland pharmacy services. The different LTC facilities all run differently (different staffing, workflow, computer system, etc). Keith is currently working on some solutions to streamline these facilities and of course find some areas for cost savings (as everyone must now do with the new pharmacy services consolidation).

My project was to do a literature search to see if there are any standards about clinical pharmacy services in LTC. For example, how often should med reviews be done? Some sites are doing them every 3 months and some every 6 months, etc. The BC college of pharmacists has some standards that must be followed. My literature search was quite unsuccessful. A few articles seemed like they might be useful but this journal was not available online. One set of published standards did not really provide the information that I was looking for.

Leadership vs. management:
Management is about coping with complexity while leadership is about coping with change. Management involves planning whereas leadership involves developing a vision or direction. Management sets guidelines, targets, plans, and ensures that the necessary tasks, etc get done but Leaders develop the vision and life of this framework set out by management. They motivate the people within an organization and are proactive in their thinking and planning.

Critical Care – Dexmedetomidine

haleygill — Fri, 30 Apr 2010 14:59:25 +0000

Attached is the presentation I gave to the LGH pharmacy staff and ICU nursing staff on Dexmedetomidine.

DEX-ICU[1]

Critical Care – Med Rec

haleygill — Wed, 28 Apr 2010 05:23:38 +0000

Here is a great example of the importance of Medication Reconciliation… A lady was admitted to hospital with query LLL pnumonia. She has a history of Seizure disorder but her valproic acid was not restared while in hospital. 6 days later she was completing her course of antibiotics for her pneumonia and almost ready for discharge when she started seizing. She was in status epilepticus for over an hour (they only gave 1 mg of lorazepam at a time for the first 3 doses, then they hit her with 4 mg and that finally did the trick) and required airway support with intubation and ventilation and was therefor transferred to ICU last night. This morning she was looking better and it was planned for her to be extubated. Then around noon today she went febrile (after 8 days of moxi). Cultures were sent so we’ll see what comes back. Her pneumonia seemed to have cleared but she may have aspirated while seizing AND her seizures could have been prevented!!

Critical Care – HIT

haleygill — Wed, 21 Apr 2010 05:51:35 +0000

My patient has HIT (heparin induced thrombocytopenia). It’s the first time I’ve ever actually seen it. His platelet count dropped from 180 to ~70. The biggest drop happened on about day 12 of heparin therapy which is a bit late for HIT so we did a HIT assay which came back positive. Heparin has been stopped for a dew days already due to low plts but now we need to anticoagulate him b/c pts with HIT are at increased risk of clotting. I recommended an argatroban infusion which was started today. I will follow up on the PTT tomorrow.

Critical Care – Week 2

haleygill — Mon, 19 Apr 2010 01:38:04 +0000

ICU week 2 started off as a really busy week and then things slowed down a bit by Friday. It’s also been a sad week. A patient came to us after having a drain put into her head following a subarachnoid hemorrhage. Prior to the bleed she’d had a headache for a few days and was found unconscious. She remained completely unresponsive in the ICU despite no sedation. She was determined to be brain dead later on in the week. Her organs were donated and will give life to others.

Some clinical interventions from the week:

A patient was on levothyroxine PTA and it had not been ordered in hospital. There were no issues with drug interactions or administration as the drug can be crushed and given via the NG tube so I recommended to restart it.

A patient was on Valproic acid and phenytoin for history of seizure disorder. Neither drug was started when he was transferred to us from a Fraser Valley hospital. I found 2 phenytoin levels from a few days before that were supratherapeutic so I ordered a phenytoin level which was now within range and recommended starting phenytoin suspension at a slightly lower dose. Phenytoin suspension interacts when given NG and patients are getting tube feeds and the feeds must be stopped for 2 hours prior to and 2 hours after phenytoin administration. I also recommended restarting the VPA.

A patient was extubated and her ranitidine for stress ulcer prophylaxis was not stopped so I recommended to d/c the ranitidine.

A patient was on a subtherapeutic dose of iron for IDA. I recommended to increase the iron from BID to TID.