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Diminishing Returns: The MIC Creep Dilemma with Vancomycin

The story of vancomycin all started when a missionary from Boreno sent a sample of dirt to a friend at Eli Lilly. The compound isolated had activity against most gram positive organisms. In fact, it got its name from the word ‘vanquish.’ Vancomycin was FDA-approved in 1958. [1]

Vancomycin is still a powerful tool against gram positive organisms, but there are some important learning points for using it properly in the critically ill ED patient.

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By |2016-11-11T18:41:39-08:00Jan 16, 2013|Tox & Medications|
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Trick of Trade: Rule of 10’s for burn fluid resuscitation

 

A patient presents with burns to both his arms, chest, and abdomen (anteriorly only) from a flash fire. That’s about 27% total body surface area (TBSA). So how much IV fluid should be given?

Be aware of a phenomenon known as “fluid creep”, where patients actually get WAY too much IV fluids than they should, which can cause delayed complications such as ACS, pulmonary edema, and compartment syndrome. Don’t forget that patients often get a lot of IV fluids in the prehospital setting, which should also be factored in.

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By |2019-01-28T22:08:28-08:00Jan 15, 2013|Trauma, Tricks of the Trade|
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Trick of the Trade: Reducing the metacarpal neck fracture

General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video below (automatically starts at 2:25 for the actual procedure). What if this approach doesn’t work? The fracture fragment remains immobile despite your best efforts.

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By |2019-01-28T22:08:52-08:00Jan 8, 2013|Orthopedic, Tricks of the Trade|
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Paucis Verbis: Composition of intravenous fluids

iv bagThere has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.

This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.

PV Card: IV Fluid Formations


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Update 1/4/13

After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.

Has this JAMA study changed your approach to ED intravenous fluid management?

It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.

Reference

  1. Yunos N, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572. [PubMed]
By |2021-10-08T09:49:07-07:00Jan 3, 2013|ALiEM Cards, Tox & Medications|
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