Adventures in Intervention

1
Adventures in Intervention

• Christine Kirsher Chad Kobayashi John Johnson
• Sandy Johnson

2
Patient Demographics

• Patient Name BY
• Age 65
• Race Caucasian
• Sex Female
• Height 64
• Weight 59 kg
• Date of Admission 11/25/2004

3
History of Present Illness

• Involved in a motor vehicle accident resulting in
  multiple traumas requiring surgery
• Transferred to CCU
• Currently on ventilator
• Receiving enteral tube feeding, NPO
• Important past history peptic ulcer
  disease/esophagitis

4
Health Care Team Involved

• Physician
• Residents
• Critical Care Nursing
• Nutrition Specialist
• Pharmacist

5
Medication History

• Morphine Sulfate 2-4mg Q4-6H PRN Pain
• Ancef 2gm Q8H
• Lovenox 30mg BID
• Fosphenytoin 100mg PE BID
• Insulin R SS PRN
• IV fluids D5 1/2NS with 20mEq KCl/L at a rate of
  125mL/Hr
• PE Phenytoin Equivalents

6
Lab Data

• WBC 4000/mm3
• (3200-9800/mm3)
• Hgb 11 gm/dL
• (F 12-15 gm/dL)
• Alb 2.1 gm/dL
• (3.5-5 gm/dL)
• K 4.1 mEq/L
• (3.5-5.2 mEq/L)
• CO2 30.5 mEq/L
• (23-30 mEq/L)
• SCr 0.7 mg/dL
• (0.5-1.4 mg/dLl)
• CrCl 69.2 mL/min
• (75-125 mL/min)

• Calcium 8.3 mg/dL
• (8.6-10.3 mg/dL)
• Hct 39
• (F 36-44)
• Platelets 252,000/mm3
• (150,000-450,000/mm3)
• Na 141 mEq/L
• (134-149 mEq/L)
• Cl- 97 mEq/L
• (95-108 mEq/L)
• BUN 12 mg./dL
• (8-18 mg/dL)
• Glucose 27 mg/dL
• (80-120 md/dL)
• Free Phenytoin 0.7 µg/mL
• (1-2.5 µg/mL )

7
1st Rph Intervention

• Rph noticed not receiving stress ulcer
  prophylaxis (SUP)
• SUP can cause acute hypovolemia and end organ
  injury in the critically ill
• Mortality 48.5-87.5
• Those on ventilator a higher risk for SUP
• Rph recommended Protonix IV, 40mg infused over 15
  minutes for 7-10 days.
• Patient successfully removed from ventilator and
  SUP never developed

8
2nd Rph Intervention

• CCU nurse concerned that serum phenytoin level
  subtherapeutic
• Rph noted low serum albumin levels and confirmed
  patient was actually within therapeutic phenytoin
  range

9
Conclusion

• Rph plays important role in CCU setting
• Rph noticed that patient was high-risk for SUP
  and made drug recommendation to prevent SUP
• Rph considered lab values as a whole and
  determined patient was receiving enough phenytoin