Medicine: The Ultimate Team Sport

I have the great fortune of working in one of the top University Hospital’s in the nation.  Everyday I work alongside medical students, interns, residents, fellows, attending physicians, Pharm D’s, and other medical professionals. After being in medicine for 20 years now, and for the first time in my career, getting to work in academic medicine, I can now see just what a team sport medicine really is. Academic medicine, unlike that seen in a community hospital, is truly a massive team of individuals working toward a common goal; to take the care of the patient and offer the latest and greatest that cutting edge medicine has to offer, from some of the brightest minds.

In the past, I had mistakenly assumed that the guys and gals in the white coats, were all knowing. In fact, I thought knowing all the answers to all of the questions was required for the job. After being in academic medicine now for roughly five months, nothing could be farther from the truth. I see everybody on the team get stumped or not know the answers to the question of the hour or what medicine is best, or what the normal value might for a particular parameter. Because medicine is such a broad, comprehensive science, it’s just impossible to know everything. It’s ok not to know; it’s just not ok to not seek the answer or keep learning. That’s what makes medicine the ultimate team sport!!

 

In my opinion, you must have the humility needed to seek help for your teammates. Chances are, your weakness my be their strength, and vice versa. I see it everyday! I see very smart, well educated, highly talented doctors and doctors in training, seek help from others on the team. There is no shame in one’s game for asking to have another team member to lend their expertise in the fight for victory. This is especially true when shouldering the ultimate responsibility of caring for a fellow human being. That’s what, in my opinion, takes a good team and makes them great. We’re all trying to move the ball down the field and score one for the patients that have entrusted us with their care, and often times, their lives.

Medicine; the ultimate team sport!

Red Man Syndrome

 

Background

This week while on rounds at work, one of the differential diagnoses that was mentioned for a patient on our list, was Red Man Syndrome. The patient had Stevens-Johnson syndrome, which I had learned about in respiratory school, but I had never heard of Red Man syndrome before. Being curious, here’s what I learned when I inquired further about red man syndrome.

Introduction

Vancomycin is an antibiotic that is commonly used to fight various infections. However, like all

medications, vancomycin administration is not without risk. Vancomycin can cause two types of hypersensitivity reactions:

• red man syndrome
• anaphalyxis reaction

Signs

Some of the signs associated with red man syndrome include the following:

• puritis
• erythematosus  rash on the face and neck
• some less frequently seen signs are

o   hypotension

o   angioedema

Symptoms

• patient c/o diffuse burning and itching
•  discomfort
• dizzy
• agitated
• headache
• chills and fever
• parasthesia around the mouth
• in severe reactions:

o   chest pain

o   difficulty breathing

Timing of Signs and Symptoms
signs and symptoms typically present 4-10 minutes after infusion of Vancomycin or soon after completion of the medication infusion typically associated with rapid I.V. infusion (< 1 hour) after first infusion of Vancomycin. To help avoid such potentially harmful reactions associated with Vancomycin, most hospitals has as their protocol, to infuse at 60 min. as a minimum. Any rate of infusion faster than that, places patients at risk for reaction

Links

Red man syndrome has also been linked to administration of Vancomycin when given via intra-peritoneal route or orally. In years past, red man syndrome was thought to be caused by the impurities seen in Vancomycin preparations and earned its name, “Mississippi Mud”.

Reaction mechanism

• mast cell degranulation
•  IgE and complement involvement

Summary

• Vancomycin should be given over at least one hour interval.  Longer infusion times should be used if giving larger doses  (Vancomycin > 1 gram)
• Vancomycin better tolerated when given in smaller, frequent doses
• If unable to give over prolonged infusion times, pretreatment with antihistamines combined with H₂ antagonist can be protective

Reference:

1. Sivagnanam, S., Deleu, D. Red man syndrome. Crit Care 2003, 7: 119-120.

Procalcitonin: What is its value clinically?

Introduction

This week at work we had a patient that presented to the ICU from an outside hospital. The patient had an anaphylactic reaction that caused the upper airway to be compromised. The team at the outside hospital tried to intubate the patient, but was unsuccessful. The patient required an emergency tracheotomy, and was subsequently transferred to a tertiary facility. During my rounds, I noticed that the Procalcitonin (PCT) level on admission was 7.1. Not being familiar with PCT, I decided to investigate what Procalcitonin was, how useful the biomarker is clinically, and how it is used to help guide care for the patient. In other words, I wanted to answer the question; what is the utility of Procalcitonin, clinically? Here’s what I found out.

Procalcitonin is a prohormone precursor of calcitonin that is expressed mainly in C cells of the thyroid gland. The conversion of Procalcitonin is inhibited by different cytokines and bacterial endotoxins. The main utility of Procalcitonin is to establish the presence of bacterial infections, because serum Procalcitonin levels rise and fall sharply in bacterial infections. In a healthy person, PCT levels are typically very low.

When is PCT of any value?

Procalcitonin has some limitations and its utility is variable, depending on the setting and age population. However, Procalcitonin can be reliable used to guide antibiotic therapy and has been shown to reduce morbidity and mortality Procalcitonin levels can be useful in the following:

-       adult ICU patient’s to help guide discontinuance of antibiotics

-       once PCT levels have dropped to 0.5-1 ng/mL, it is generally accepted to stop antibiotic coverage

-       PCT levels are also helpful in determining when to give antibiotics. For example, PCT levels are particularly helpful in patients with respiratory tract infections such as: COPD, community acquired pneumonia, bronchitis, URI/LRI infections ----> start antibiotics if PCT > 0.25-0.5 ng/mL

When is PCT of no value?

-       Viral infections

-       The use of PCT levels should not be used for intensification of antibiotics in adult ICU patients, because this was associated with an increase in mortality

-       Currently there is insufficient evidence to support the use of Procalcitonin-guided antibiotic therapy in neonates with sepsis, children with unknown source of fever, or in the post-operative, at risk for infection population.

Therefore, Procalcitonin is just another tool in a clinician’s kit that can be used to help in making a diagnosis and guiding treatment, but like so many other indices and biomarkers, it is not the Holy Grail.

Reference:
1. Soni, NJ., Samson, DJ., Galaydick, JL., Vats, V., Huang, ES., Aronson, N., Pitrak, DL. Procalcitonin-Guided Antibiotic Therapy: A Systematic Review and Meta-analysis. J. of Hosp Med; Vol. 8, No. 9, 2013; 530-540.
2. Prkno, A., Wacker, C., Brunkhorst, FM., Schlattmann, P. Procalcitonoin-guided therapy in intensive care unit patients with severe sepsis and septic shock - a systematic review and mata-nalysis. Crit. Care 2013, 17R291
3. Morris, C., Paul, K. Procalcitonin-Guided Antibiotic Therapy for Acute Respiratory Infections. American Family Physician, Vol 94, No. 1, July 1, 2016; 57-58.

Spontaneous Bacterial Peritonitis

As I mentioned in my introductory blog, one thing I will be doing is sharing with you, the reader, cases that I see clinically at work. Working at a University Hospital, I have the opportunity to see and learn about a wide array of pathologies. I got the idea from an article I read that said you should always carry a 3X5 card in your shirt pocket when in clinic. If you see a patient with a particular disease that you’ve never heard of or know nothing about, jot it down, look it up, and learn about it. Add your findings to the 3X5 card and store them in a box, much like you’d use to store recipes in. I thought this would be a fun way of learning something each week that will surely translate into my training as a PA, so I’m now doing that and want to share with my followers. At the end of the year, I will have assembled a box full of new knowledge that I can refer back to at points along the way.

On my job, I get to round with interns, medical students, residents, fellows and attending physician’s in the ICU. This week there was a patient that had SBP. Not knowing what that was, I took the opportunity to ask a resident that I have befriended. After telling me a little about SBP, I pulled an article and will share with you the highlights of Spontaneous Bacterial Peritonitis (SBP).

Introduction:

SBP is an infection of ascetic fluid without a definitive abdominal source that can be treated surgically. SBT is common in cirrhosis of the liver with concomitant ascites. Patients that survive such an infection have 1 and 2 year mortality rates of 70% and 80% respectively, and the recurrence rate within a year of the initial infection, ranges from 40-70%.

Pathogenesis:

The pathogenesis of SBT is caused by a prolonged bacteremia, secondary to a compromised host, intrahepatic shunting, colonized blood, and ineffective antibiotics. Predictors of SBT are an increased bilirubin >2.5mg/dL and low ascetic protein level < 1g/dL. The typical offending pathogens are gram-negative rods and streptococci.

Signs and symptoms:
Some common signs and symptoms that are seen with SBT are listed here

• Fever, abdominal tenderness
• GI bleeding, nausea & vomiting
•  Chills, change in mental status
• Cytologic analysis of fluid obtained by paracentesis is the best way to assess and identify SBP (see link for procedure) https://www.youtube.com/watch?v=zyvHGmigvD0
• The best information is relative to the neutrophil level ---> 250-500 cells/mL
• pH and lactate measurement of fluid is not particularly helpful or useful

Primary SBP vs. Secondary SBP:

Primary SBT has the following:

• monomicrobic
•  PMN’s >250 cells/mm³
• Gram negative rods (GNR’s)

Secondary SBP:

• Total protein >1g/dL
• Glucose < 50mg/dL
•  LDH > upper limits of normal (ULN)
• PMN’s > 250 cells/mm³

Treatment:

The treatment for SBT is typically pharmacologic in nature and the antibiotics used will depend on local epidemiologic patterns. Empirical antibiotic s are recommended. Several antibiotics were mentioned in the article I read, but two of the common ones were Ceftaximine and Ceftriaxone. After the initial paracentsis, it is recommended that a second diagnostic paracentesis be done 48 hours later, in order to assess the efficacy of the antibiotics being used for treatment. The literature says that is there is not a 25% or greater improvement in the decrease of PMN’s. If you aren’t able to reduce the nutrophile count by 25%, it is seen as a failure of treatment.

Albumin:

The single largest predictor of death in SBP is renal failure. With that, the question of Albumin administration has to be asked. Who gets Albumin?

•  serum Bilirubin > 4mg/dL
• serum Creatinine > 1mg/dL
• BUN > 30mL/dL

It should also be mentioned that the dose for Albumin be limited to 100 g/dose. If the SBP is complicated, then Albumin should not be administered. If renal function is NOT compromised and the is NO encephalopathy, then Albumin should not be administered

Prophylaxis:

Prophylactic treatement should be reserved for patients at greates risk for SBP. So, who is at greatest risk for the development of SBT?

•  Past history SBP
• Upper GI bleed
• Low total protein level in ascetic fluid

Reference:

1. Alaniz, C., Regal, R.E. Spontaneous Bacterial Peritonitis. P.T. 2009 Apr; 34(4) 204-210.