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PCU Orientation

By:

Juan Toledo, Pharm.D.

PCU Pharmacist

Heparin

• Parental anticoagulant

• MOA: accelerates the activity of antithrombin III to inactivate thrombin

• Indication: STEMI, unstable angina, PE, DVT, Afib with or without thrombus, mechanical heart valve

• No renal adjustment

Scenario #1

JT was started on a heparin drip for the treatment of pulmonary embolism. 1. aPTT level 6 hrs after start of the heparin drip is

subtherapeutic at 40 seconds 2. Following heparin protocol the nurse text pages the

floor pharmacist for a heparin bolus and increases the infusion rate at 03:30.

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aPTT 30-45: Increase heparin rate by 190 units/hr. Bolus 2,400 units. Next aPTT 8 hrs after bolus

Scenario #1

1.04:00 Nurse administers the heparin bolus

2.05:30 Phlebotomist draws an aPTT level with the morning labs.

3.Day shift nurse receives a call that the aPTT is 110 seconds

• Q: How should the day nurse respond to the elevated aPTT?

UCSD Guideline

Assess aPTT levels:

• Check the time aPTT lab was drawn

• Confirm that it has been: – 6 hrs after rate change or

– 8 hrs after a bolus administration

• If labs were drawn at the appropriate time and aPTT is not at goal, the nurse should page the floor pharmacist and respond according to the heparin protocol.

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Draw next aPTT 8 hrs after bolus!!

aPTT 30-45: Increase heparin rate by 190 units/hr. Bolus 2,400 units. Next aPTT 8 hrs after bolus

Scenario #1: Next Steps

• Level was not drawn 8 hrs after the bolus

• Disregard the level because it is not reflective of the new heparin drip rate.

• An aPTT should be redrawn at 12:00.

Scenario #1: Prevention

• Problem upon transfer

– Especially upon transfer from the E.D.

• Use the anticoagulation monitoring flow sheet

• Do not assume the bolus and infusion were started at the same time

– Delays from Pharmacy delivering the bolus

• Problematic at change of shifts

– Sign out when next aPTT due

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Hover to Discover

Scenario #2

1. 06:00 VD started on a heparin bolus and a heparin drip

2. 8 hours later aPTT 135 secs 3. Nurse thinks the high aPTT may have been due

to a draw from the same line the heparin was infusing

4. Heparin was held and another aPTT 155 secs 5. Nurse notices VD’s baseline aPTT = 50 secs Q: What would be the next course of action?

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•06:00 heparin bolus given •1400 (8hrs later) aPTT= 135 secs •Next draw aPTT= 155 secs •Baseline aPTT= 50 secs

UCSD Guideline

Exclusion from heparin guidelines:

• If a patient’s baseline aPTT is prolonged > 35 seconds, then aPTT may no longer be an accurate in monitoring the efficacy of heparin.

– Normal baseline aPTT ranges from 25 to 34 secs

• The nursing driven heparin protocol may not be ordered, and a physician or pharmacist driven protocol will be needed.

Scenario #2: Next Steps

• Nurse was correct to hold the heparin and order a repeat level to assess the elevated aPTT

• The pharmacist and physician should be notified as soon as possible since the baseline aPTT is prolonged.

• Prolonged baseline aPTT excludes the patient from typical heparin guidelines

• Further monitoring will likely include both anti-Xa and aPTTs

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Pharm Driven Heparin Protocol

• Anti-Xa is a more reliable measure of anticoagulation in certain patients on heparin drips vs. PTT

– Patients with baseline elevated PTT’s

• Thrombophilia or Factor Deficiency

• Anti-phospholipid Antibodies or Lupus Anticoagulant

– Patients on low heparin doses based on weight

• PTT “therapeutic” on doses <<12 or 18 units/kg/hr

– Patients with unexpected PTT response to heparin • Persistently subtherapeutic despite increasing heparin doses

Scenario # 4

• JG, 65 y/o M, 83kg, presents to ED with c/o CP/SOB

• Found LV thrombus high intensity heparin drip initiated while bridging to warfarin

• Labs on admission:

− INR: 1.2 Scr: 1.42

− Ht/Wt: 73”/86 kg PTT: 32.8

− Hgb: 12.9 Hct: 39.5

Scenario # 4

1. Baseline PTT 32.8

2. 1500: Bolus dose of 6,600 units

3. 1500: Rate 1500 un/hr

4. 1815: PTT came back at 279.8

5. 1930: Heparin was held

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Scenario # 4

1. 2300: Heparin restarted at a decreased rate of 1210 un/hr

2. 0400: PTT was elevated at 105.3

3. Over the next several days, heparin dose was titrated down to

4. PTT continued to be supra-therapeutic (despite being drawn at appropriate times)

570 un/hr

Scenario # 4

Q: Could this patient benefit from Anti-Xa monitoring?

Scenario # 4

May have benefited from Anti-Xa monitoring due to very low heparin dose

•Check rate against weight – Initial 18 un/kg/hr vs 4 d later 6 un/kg/hr

•Always double check that levels were drawn at appropriate times:

– 6 hrs after rate change or

– 8 hrs after a bolus administration

– ****WATCH OUT FOR PHLEBOTOMY DRAWS****

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Scenario # 4: Next Steps

1. D/C current heparin order, and reorder as a verbal order for the on-call MD

2. Communicate change with RN

3. Reminder Only 2 therapeutic Anti-Xa levels in a row needed for QD monitoring

Scenario #5

Patient’s aPTT has been therapeutic on a heparin drip running at 1,700 units/hr for the past 5 days

1. Last aPTT= 70 seconds 2. Physician discontinued the heparin drip tonight for a

procedure tomorrow afternoon. 3. After the procedure, the MD reorders the heparin drip to

run at 1,200 units/hr (based on patient’s weight). Q: What should the nurse consider doing upon seeing the

new heparin order?

UCSD Guideline

There is no written guideline for this:

• When restarting heparin drip check patient’s previous aPTT to see if it is at goal

• If patient’s aPTT was previously therapeutic, then page physician and pharmacist to see if you can restart drip at the previous rate

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Therapeutic

Scenario #5: Next Steps

• Contact the physician and pharmacist to request a heparin bolus and restart the heparin drip at previous rate.

• Restarting at this rate may reduce the time needed to titrate up to a therapeutic aPTT.

Heparin weight based nomogram

• R.M. is admitted for new onset afib.

• He is now found to have left leg swelling.

– Ultrasound is positive for DVT.

– CrCl of 29.

– Weight is 96 kg.

• MD orders a heparin drip per protocol.

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Draw next aPTT 8 hrs after bolus!!

aPTT 30-45: Increase heparin rate by 190 units/hr. Bolus 2,400 units. Next aPTT 8 hrs after bolus

Great Catch July 2013

• Katie Brown RN is July Great Catch Winner

• Found weight entered in heparin drip order, matched weight entered in EPIC

• Way to Go! Great Catch

• Right?!?

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Look at the Patient

• She questioned the weight entered EPIC

• The patient did not look 120 kg

• The weight was entered as kg instead of lb

• WOW! OVERDOSE!!!!

• Fortunately the patient was transferred to Katie soon after drip was started

• Weight was corrected and drip rate lowered

Breaking News

• Goal range for high intensity protocol is 66 –115 seconds

– Previous goal range is 60 – 90

• Therapeutic aPTT goal range for low intensity protocol will be

• Goal range for low intensity protocol is 66 - 105 seconds

– Previously goal range is 60 – 80

Heparin for High Bleeding Risk

• Post neurosurgical procedures, or other surgical procedures (needing anticoag)

• Stable ICH or recent hemorrhagic stroke (new DVT or PE)

• Acute stroke with any indication for anticoag

• Cerebral sinus venous thrombosis

• Coagulopathy (ex. liver disease) needing anticoagulation

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Heparin for High Bleeding Risk

• Previously no RN driven protocol

• MD had to titrate

• Now RN to titrate goal aPTT range is 55 – 85

• NO INITIAL BOLUS or DURING TITRATION

New Start Coumadin

• YY is a 79 year old Asian male with gastric cancer scheduled for open subtotal gastrectomy

• PMH – Gastric Cancer

– Dyslipidemia

– DM II

– HTN

– CAD s/p PCI stents x2

Hospital Course

• 6/17: EKG

– NSR at 61 bpm

• 6/21: partial gastrectomy

• 6/22: post-operative atrial fibrillation

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Hospital Course con’t

• 6/22: Cardiology Consult

– Continue metoprolol and add diltiazem

– No anticoagulation at this time

• 6/26: remains in atrial fibrillation despite metoprolol and diltiazem

Hospital Course con’t

• 6/26: Cardiology Consult

– Rec: start warfarin 5mg

• 6/27: started warfarin 5mg daily

• 6/29:

– Now NSR

– Plan = discharge on 6/30

What is Wrong?

Date INR Warfarin

6/21 1.2 (1805)

6/27 5mg (1906)

6/28 1.3 (0600) 5mg (1721)

6/29 none 5mg (1800)

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Hospital Course con’t

• 6/30:

– INR (0425) = 7.4

– INR (0750) = 8.7

– Plan = hold warfarin and keep patient overnight

• 7/1:

– Overnight patient developed acute GI bleed

– INR (0500) = 10.4

Hospital Course con’t

• 7/1: – Vitamin K 10mg SQ x 1

– INR (1735) = 3.5

– Hold warfarin

• 7/2: – INR (0500) = 5.2

– Vitamin K 10mg SQ x 1

– Plan = restart ASA and clopidogrel; follow-up with PCP and outpatient cardiologist

Warfarin Initiation Pearls

• Start appropriate dose based on patient specific factors

• Obtain baseline labs <48hrs before starting

• Monitor INR daily until stable

• Administer Vitamin K po or IV when appropriate

• Dose adjustments should occur after 3 – 5 day

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Warfarin Dosing

• Always evaluate new medications for DDI and consider empiric dosage adjustments

• Continue bridge for 5 days and 2 consecutive goal INRs

• Follow-up <1-2 weeks after discharge

• Refer to UCSD Dosing Guide for recommendations

Anticoagulation Counseling

• Warfarin, Apixiban, Dabigatran, Rivaroxaban pharmacists are required to counsel before discharge

• If discharge orders include one of the meds – Check if discharge counseling has been done this

admission

– If not page floor pharmacist to come counsel patient

– The patient must be counseled before discharge

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The education needs to be done each admission. Even if they were just educated last month.

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Not resolved yet. When discharge orders placed, PAGE YOUR PHARMACIST TO COME COUNSEL !

Scenario #7 LU was started on enoxaparin 30mg SC BID for DVT

prophylaxis.

1. 4 days later, the nurse sees an anti-Xa level ordered for the patient

2. The nurse is curious as to why anti-Xa levels are being monitored and is not sure when to draw it

UCSD Guideline

Draw time: • Anti-Xa levels must be drawn 4 hours after dose

administration When to monitor anti-Xa: • Weight < 45 kg or > 120 kg • BMI ≥ 40 • Pregnancy • CrCl < 30 ml/min • Surgical patients

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Scenario #7: Next Steps

• The nurse should draw the Anti-Xa level 4 hrs after administration of enoxaparin where the enoxaparin concentration is at its peak.

• Normally lovenox given at 9am

• Normally drawn at 1pm

– If give early = draw level 4 hr post dose

– If give late = draw level 4 hr post dose

• Only 4 hr post dose goal anti-Xa level

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C= Compatible

U = means not studied

IVIG or Rituximab

• Given once day

• Titrated slowly to prevent infusion related reactions

• Should be charted as “given” initially (this will charge the patient)

• Subsequent rate changes should be charted as “iv rate change”

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No dose charged b/c not charted as given

$$$$ Expensive med to give for free $$$$

HANDLING HAZARDOUS DRUGS

A refresher Emily Min, PharmD emin@ucsd.edu // pgr 4442 Tammy Hsu, PharmD Candidate t3hsu@ucsd.edu

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• Hazardous drugs include those used for cancer chemotherapy,

antiviral drugs, hormones, etc.

The Centers for Disease Control and Prevention (CDC; 2015)

How do I Know what’s hazardous?

• Listed in the administration instructions and in Pyxis

• Labeled on the bag if an IV medication

• Can reference list from MCP 323.1, Attachment G

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Group 1: minimal risk

• Common meds:

• Warfarin (Coumadin)

• Fluconazole (Diflucan)

• Paroxetine (Paxil)

• Risperidone (risperdal)

• Clonazepam (Clonopin)

• Chemotherapy-tested disposable gloves

recommended during handling and/or administration

of any injectable medications

Group 2: moderate risk

• Common meds:

• Finasteride (Proscar)

• Ganciclovir (Cytovene)

• Azathioprine (Imuran)

• Mycofenolate (Cellcept, Myfortic)

• Gloves (+ gown/face mask if risk of splashing) required for handling medication

• Gown/gloves should be worn while handling bodily fluids (+ face shield if risk of splashing)

• Do not crush or split tablets Should be done by the pharmacy in the IV room

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Group 3: high risk

• Includes parenteral medications

• Two pairs of chemotherapy-tested disposable gloves and

gown must be worn during handling and/or

administration

• Gloves, gown and face mask if risk of splashing required for handling medication

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Protecting others

• Post sign to alert other care team members (MCP 323.1, Form D3000)

• Send lab samples with a special sticker (Label 151-1020)

• Dispose of drug packaging and anything that came into contact with hazardous drug or patient’s bodily fluid in a chemotherapy waste bin

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Signage

Labels for Lab specimens

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Questions?

• Ask your pharmacist or supervisor

• Use MCP 323.1 for reference

RESOURCES

• 1. The Centers for Disease Control and Prevention (CDC; 2015)

Glucose Management for Patient on Insulin Drip

Mandana Moshtael, Pharm.D. Candidate

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WEB REF

Medication Resources

Insulin and Nutrition on Hold Unexpectedly

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Patient on Insulin Drip

• Monitor glucose q1h until glucose in normal range x 3

• If BG<70 mg/dL or 70-79 mg/dL and symptomatic

– Follow hospital hypoglycemia protocol

– Recheck BG within 15 minutes per protocol

– If >2 consecutive BG<80 mg/dL, notify MD

– Call Pharmacy for further consultation

• Continue q 1-2 hour glucose monitoring per protocol

Mr. John Doe

BG: 74 22:41

BG: 371 06: 52

~8 hours Later

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CIWA-Ar Nursing In-Service

Brittney Choi, Jane Lim, and Christopher LiN PharmD. Candidates

Juan Toledo, PharmD.

Alcohol Withdrawal

Pathophysiology: Imbalance of GABA & glutamate neurotransmitters

Etherington, J M. (1996). Canadian family physician, 42, 2186-2190.

Time Course of Alcohol Withdrawal Symptoms

Kattimani S, Bharadwaj B. Industrial Psychiatry Journal

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Medication Strategies

• Scheduled benzodiazepines

• Taper over several days

Fixed Schedule

• Given in response to symptoms

• Treat until CIWA < 8

Symptom Triggered

Old School Librium Taper

Pros Cons

New School CIWA Protocol

Pros Cons

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Benzodiazepine Dosing

Fixed Librium (Chlordiazepoxide) 50 mg q6h

Medication given regularly

Symptom Triggered

Valium (Diazepam) 10 mg q1h prn CIWA > 8

Benzodiazepines for Alcohol Withdrawal

Half life Active Metabolite Indication

Valium (diazepam) 30 – 60 hours Yes First line

INR < 1.4 and/or AGE < 60

Librium (chlordiazepoxide)

5 – 30 hours Yes None

Ativan (lorazepam) 12 hours No 2nd line

INR > 1.4 and/or AGE > 60

Benzodiazepines – Onset of Action

Diazepam Clorazepate Chlordiazepoxide Oxazepam Alprazolam Clonazepam Lorazepam

More Lipid Solubility Less (Faster) (Absorption) (Slower)

Faster Onset of Effect Slower

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Benzodiazepines – Metabolism

Oxidation (CYP3A4)

Conjugation

Diazepam

Lorazepam

Live

r Desmethyldiazepam

Oxazepam

Benzodiazepines – Duration of Action

Lorazepam Diazepam

Shorter Longer

(No Active Half-Life (Active Metabolite) Metabolite)

Shorter Duration of Action Longer

Benzodiazepines for Alcohol Withdrawal

Half life Active Metabolite Indication

Valium (diazepam) 30 – 60 hours Yes First line

INR < 1.4 and/or AGE < 60

Librium (chlordiazepoxide)

5 – 30 hours Yes None

Ativan (lorazepam) 12 hours No 2nd line

INR > 1.4 and/or AGE > 60

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Charting CIWA-Ar Scores

Nursing Orders

Nursing Orders

CIWA Measurement: NOW THEN EVERY 2 HOURS “If CIWA-Ar score is greater than 8, re-assess with repeat CIWA-Ar score in 1 hour. If CIWA-Ar score is 8 or less, assessments may be spaced out to every 4 hours. Do not wake patient to perform CIWA-Ar scoring. May discontinue CIWA-Ar assessments if all scores in the previous 24 hours have been 8 or less. Document all assessments in the CIWA-Ar flowsheet.”

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Nursing Orders

NOTIFY PROVIDER IF: ONGOING

“CIWA-Ar GREATER than 15”

Nursing Orders

NOTIFY PROVIDER IF: ONGOING “Patient has any disorientation, hallucinations, or is not improving despite benzodiazepine therapy”

Nursing Orders

NOTIFY PROVIDER IF: ONGOING “There Is suspicion that symptoms are due to a condition other than alcohol withdrawal”

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Nursing Orders

NOTIFY PROVIDER IF: ONGOING “Patient is on Med/Surg Level of Care AND Is requiring 3 consecutive hourly doses of benzodiazepine; Consider moving patient to IMU Level of Care”

Nursing Orders

Contact Protocol Champions for Any Questions Regarding Alcohol Withdrawal Protocol: ONGOING “For any routine questions about the alcohol withdrawal protocol itself (regarding dosing threshold, frequency, response to therapy, or other concerns), contact Dr. Ian Jenkins by pager during daytime hours, or pager 290-1150 after hours.”

Patient Case:

• KZ is a 21 year old female with a history of alcoholism x 1 year is admitted for abdominal pain with nausea and vomiting x 2 days

• Patient is a poor historian and when asked who the president is she states, “Obama, of course! We hung out last weekend!”

• BP 110/57 HR 112 RR 23 • Ht 6’1” Wt 60kg • AST 22 ALT 7 Albumin 3.7 INR: 1.1 • AxO x 1

• The MD places her on the CIWA-Ar protocol with the following orders Diazepam (Valium) 10mg IV every 1 hour prn for withdrawal, defined as CIWA-

Ar score greater than 8

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Patient Case:

• KZ’s nurse documents her CIWA-Ar score and administers the Valium

When should the nurse assess the patient’s CIWA-Ar score next?

In 1 hour

Patient Case:

Is the nurse still following the CIWA-Ar protocol?

Yes! Patient is sleeping

Patient Case:

Is the nurse still following the CIWA-Ar protocol?

Yes! Score less than 8, can check in 4 hours

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Patient Case:

What should KZ’s nurse do?

Notify the provider!

Patient Case:

• What are options for continuously high CIWA scores?

Patient Case:

When should the nurse notify the provider?

CIWA-Ar score GREATER than ___

Patient has any disorientation, hallucinations, or is not improving ________________________________

There Is suspicion that symptoms are due to a condition ______________________________

Patient is on Med/Surg Level of Care AND Is requiring __ consecutive hourly doses of benzodiazepine; Consider moving patient to IMU Level of Care

15

despite benzodiazepine therapy

other than alcohol withdrawal

3

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Thank you for listening!

Questions?

Pt ordered 4 times daily = 4 x 4 = 16 pills/day

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Call your pharmacist tell them you are giving 4 pills per dose and request a more appropriate strength. Many times a more appropriate strength is loaded in pyxis.

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Change to 25 mg tab 2 tabs BID

Narcotic Waste

• Fentanyl pca started in PACU

• Now in IMU and new order to d/c pca

• Remove pca from pump and there is 20 ml remaining

• Go to pyxis to document the waste

• There is no fentanyl pca under the patients profile in pyxis.

Narcotic Waste

• What do I do?

A. Call pharmacy to come waste with me

B. Squirt remaining dilaudid in the toilet and hope no one notices

C. Select all meds and search for dilaudid pca

D. It doesn’t matter pharmacy is going to ireport me anyway

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Bring up pt and select waste

Search for dilaudid pca under removed meds

Select all meds

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All meds appear when you select all meds!

Avoiding Injuries: Glass Vials

• Grasp the tip with one hand; if a dot is present on the tapered tip, place your thumb over the dot

• Brace the vial with the other hand

• Break the vial in the direction away from self

• Use a filter needle when drawing up the medication

• Tip: wrap the tip alcohol wipe to avoid glass breakage Created on March 5, 2015

Lindsey Mann, PharmD Amrit Dosanjh, PharmD

UCSD Medical Center – Department of Pharmacy

Avoiding Injuries: Ampules

Created on March 5, 2015 Lindsey Mann, PharmD Amrit Dosanjh, PharmD

UCSD Medical Center – Department of Pharmacy

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Avoiding Injuries: Steroid Vials

• Place vial on hard surface

• Press down on top cap, towards surface

• Rubber stopper will fall

• Mix medication

• Holding the vial while pressing down may cause seroius insjury if glass breaks

Created on March 5, 2015 Lindsey Mann, PharmD Amrit Dosanjh, PharmD

UCSD Medical Center – Department of Pharmacy