How I Educate Series: Christina Shenvi, MD

This week’s How I Educate post features Dr. Christina Shenvi, the Director of the Office of Academic Excellence and former Associate Residency Director at the University of North Carolina, Chapel Hill. Dr. Shevani spends approximately 80% of her shifts with learners, including emergency medicine residents, off-service residents, and medical students. She describes her practice environment as tertiary care academic center. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Interactive, team-based, and collaborative.

What delivery methods do use when teaching on shift?

Verbal discussions usually with both residents and med students, where we take turns coming up with answers to things, and share ideas or resources. For example, if we are discussing the causes of falls in older adults, we go around in a circle coming up with things that contribute to the fall syndrome in older patients until none of us can think of any more. For questions with fewer options or answers, I will start with the med student and then move up to the intern and PGY3 to develop a progressively more nuanced or thorough discussion.

What learning theory best describes your approach to teaching?

Scaffolding; social constructivism.

What is one thing (if nothing else) that you hope to instill in those you teach?

A lifelong curiosity and love of learning.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I look for times when there is either a natural learning opportunity, a lull in activity, or both. If there is an interesting CT or EKG, that is a good learning moment to gather the group and briefly discuss it. If there is a lull in activity, that is a good time to discuss a given topic related to a patient we have taken care of. It sometimes comes at the expense of documentation, but teaching is a priority.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

Usually, I review notes on shift if they are available and provide feedback.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

We do what we can with what we have. There is a joint mission in academic hospitals: to care for patients *and* to teach. If the pendulum swings too far one way or the other, then one of the missions will suffer. The goal is to keep both in mind and find moments for teaching, while making other tasks, such as documentation, as efficient as possible.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I will usually ask: “Let me know if you need a hand or another set of eyes.” If it is a patient safety issue, then I will step in sooner, otherwise, there is usually time to let them try on their own.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I will usually ask the residents or students what they want to work on that day, or what they would like feedback on. By honing in on their goals, I can pay more attention to the area that they are working on, whether it is ultrasound, EKG interpretation, department flow, communication, etc. That also focuses their attention on the area, so they can work on it.

Do you typically see patients before or after they are presented to you?

After – this allows the learner the chance to gather the information first and present it so that they are the primary caregiver.

How do you boost morale amongst learners on shift?

Staying positive myself is the first goal. Focusing our energy on what we can control vs what is outside of our control is key as well.

How do you provide learners feedback?

Verbal feedback during or at the end of the shift is often the most effective because it can lead to more reflection and discussion. I also provide written feedback online after the shift.

What tips would you give a resident or student to excel on their shift?

Let your attending know what you want to work on and get feedback on. This will help them give you better quality feedback at the end of the shift, rather than “good job” or “read more”. Take ownership of your own learning, making a reading or study schedule for yourself. Pick your favorite resources and podcasts, and make regular time to use them.

Are there any resources you use regularly with learners to educate during a shift?

I often use LITFL and other online resources to show examples of EKGs, procedures, or images.

What are your three favorite topics to teach during a shift?

My fellowship training is in geriatric EM, so I enjoy teaching specifically on geriatric syndromes and falls, ACS in older adults, as well as on EKGs.

What techniques do you employ when teaching on shift?

Discussion, Q&A, elaboration (ie. taking a given case or situation and expanding to other related cases to discuss and expand the learning opportunities).

What is your favorite book or article on teaching?

Books: Make it Stick

Who are three other educators you’d like to answer these questions?

Sara Dimeo; Megan Osborne; Guy Carmelli

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Christina Shenvi, MD PhD|2023-01-03T16:41:21-08:00Jan 4, 2023|How I Educate, Medical Education, Uncategorized|

How I Educate Series: John Casey, DO

This week’s How I Educate post features Dr. John Casey, the Program Director at OhioHealth Doctors Hospital in Columbus, OH. Dr. Casey spends 100% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, nursing students, physician assistants/nurse practitioner students, and EMS students. He describes his practice environment as a busy community teaching hospital located on the city’s edge, with a diverse patient population and many socioeconomic challenges. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Use. The. Force.

What learning theory best describes your approach to teaching?

Deliberate practice. I think it’s so very important to identify an area of weakness and target it. I try and focus my teaching energy on areas where learners have blind spots and get them to engage in very targeted practice in that specific area.

What is one thing (if nothing else) that you hope to instill in those you teach?

Always be curious, and not be afraid to challenge your own beliefs – or to have them challenged!

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I try and teach my more senior residents how to incorporate junior learners and students into their workflow. When a learner locks on to you for a shift you don’t know if you’re getting a parachute or a knapsack…don’t jump out of the plane until you have identified which they are.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Nope. Department flow and metrics are part of the learning process. A lot of our job is more than medicine. To be happy and successful in this career long term you have to have a plan to manage these stressors – so better to learn it in residency while you have support from experienced emergency physicians. There will always be faster shifts, slower docs, efficient nurses, and lab slow downs – learn to work through them.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Be confident in your own abilities to manage situations, and remember you learned to be better through practice. As long as you are available to support them, and recognize the boundaries of what is safe for the patient and the learning environment, then most learners appreciate this on the other side. Earlier in my career, I probably let learners struggle a little more than I should have, and this is a place where I have learned – and grown – through feedback.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I think it’s better to let them develop as the shift unfolds. I will often ask if the learner has something in mind, and if they do I am happy to cover it – but no guarantees!

Do you typically see patients before or after they are presented to you?

I deliberately shake this up. When I see them before, I will often engage the patient in helping me get feedback on the learner. I will ask that they not specifically mention I have seen them, and give them an area to focus on (like did the resident ask similar questions to what I asked, or did they make them feel comfortable, etc.). I will then circle back and get feedback – you can learn a lot about how residents interact with patients using this method. Also – I love to go into the room while they are doing the exam and interview. Hawthorne effect aside, you can learn a ton about how the learner is doing overall!

How do you boost morale amongst learners on shift?

I work hard to pay attention to the overall mood of the shift and try and throttle accordingly. I am by nature a storyteller and like to share experiences. It’s more than just lip service when we talk about cases where we didn’t do as well as we wanted at something. Human nature is to feel like we are totally responsible for mistakes when almost always there is a substantial mix of exogenous events that lead to failure. Also – I remind learners that whatever they feel in the moment is OK – those feelings about an event change with time and perspective. Windshields in a car are big for you to look forward, and rear-view mirrors are tiny so you can remember past lesions – but focus on what’s next. Additionally….dad jokes.

What tips would you give a resident or student to excel on their shift?

Be nice. Work hard. Stay humble. If you only have enough energy for one on a given day, be nice.

What are your three favorite topics to teach during a shift?

ECG interpretation, anaphylaxis, and reading a room

What is your favorite book or article on teaching?

Thanks for the Feedback: The Science and Art of Receiving Feedback Well by Stone and Heen. I guess it’s not really a book on teaching per se, but if you can help people learn this skill (and master it yourself) it can make for a great learning environment!

Who are three other educators you’d like to answer these questions?

Dr. Katie Holmes, Dr. Deena Bengiamin, and Dr. Kristy Schwartz

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By John Casey, DO, MA, FACEP|2022-09-03T11:12:21-07:00Sep 28, 2022|How I Educate, Medical Education, Uncategorized|

How I Educate Series: Alex Koyfman, MD

This week’s How I Educate post features Dr. Alex Koyfman, who serves as core faculty at UT Southwestern in Dallas, TX. Dr. Koyfman spends approximately 90% of his shifts with learners, including emergency medicine residents, off-service residents, medical students, and physician assistants. He works clinically at Parkland Memorial Hospital which is the busiest urban ED in the country. He also spends time in their independent urgent care and ED observation unit, both of which also have a mix of different learners. Below he shares with us his approach to teaching learners on shift.

Name 4 words that describe a teaching shift with you.

Autonomy, growth, curiosity, pt advocacy

What delivery methods do use when teaching on shift?

A focused discussion based on the needs of the learner and what is high-yield in our environment.

What learning theory best describes your approach to teaching?

A mixture of multiple which is actually documented in my book The Emergency Medicine Mindset.

What is one thing (if nothing else) that you hope to instill in those you teach?

Excellence in clinical care is the ultimate form of patient advocacy and deliberate practice gets you to mastery.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Volume definitely impacts teaching as 1a) patient care, and 1b) education; they feed off of each other. The focus is on impactful clinical documentation for the transition of care, not medicolegal paranoia; it is impractical to achieve excellence in all spheres of practice. We must be thoughtful communicators at the bedside on working diagnoses and degrees of uncertainty. Each piece of information you request, you must account for in the context of the patient.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

The focus is on decision-making (practical risk stratification). Does the MDM jive with the remainder of the documentation? Have risk factors/red flags been thoughtfully explained? It helps to highlight what to focus teaching on.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Mixed bag; I can’t disagree with the more you see the more comfortable you become. Often metrics don’t jive with evidenced-based medicine, however, many of our grads will be responsible for this and judged based on it in their future careers. Thankfully, it doesn’t dominate our practice environment in an onerous manner.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Experience teaches you to get comfortable with this. It is very important to get it right for resident development. There are many more greys in EM decision-making than black or white, thus if reasonable then no need to intervene pre-emptively.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

The learner sets the tone for clinical education. At the same time, I’m not shy to bring up topics based on what we’re seeing.

Do you typically see patients before or after they are presented to you?

Depends on the stage of the learner + the volume/practical need to move things along.

How do you boost morale amongst learners on shift?

Invest meaningfully in the development of each individual I work with.

How do you provide learners feedback?

Best handled in real-time if flow allows. The next best is right after the shift. Written feedback is a formality, I am not convinced that many learners review these and items can be misconstrued. This is an area that’s easy to avoid, yet crucial to do, and takes a departmental culture.

What tips would you give a resident or student to excel on their shift?

One foot outside of your comfort zone each shift; marginal gains add up. Reflect/be proactive about anything that didn’t go smoothly or caused consternation.

Are there any resources you use regularly with learners to educate during a shift?

Heavy on foamed (emDocs, IBCC, EM Cases, etc.) with PubMed/Google Scholar literature mixed in.

What are your three favorite topics to teach during a shift?

EM mindset; decision making; high-risk, low-prevalence diseases; anything critical care; advocacy for our field in the academic arena

What techniques do you employ when teaching on shift?

Adapted from best practices here as well as paying attention to my colleagues.

What is your favorite book or article on teaching?

Thinking, Fast and Slow by Daniel Kahneman; Radical Candor by Kim Scott

Who are three other educators you’d like to answer these questions?

Brit Long, MD; Manny Singh, MD; Alex Sheng, MD; Marina Boushra, MD

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Alex Koyfman, MD|2022-09-20T21:32:20-07:00Sep 21, 2022|How I Educate, Medical Education, Uncategorized|

This week’s How I Educate post features Dr. Graham Snyder, the Associate Program Director at the University of North Carolina and Director of Education for WakeMed Health and Hospitals. Dr. Snyder spends approximately 90% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a Level 1 trauma center that sees 125,000 patients annually. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Practically Academic, Comradery, Rejuvenating

What delivery methods do use when teaching on shift?

YouTube, just-in-time sim task-training, observation and feedback of the resident teaching the student.

What learning theory best describes your approach to teaching?

Cognitive learning

What is one thing (if nothing else) that you hope to instill in those you teach?

Love and an appreciation of the honor of caring for patients in their time of need.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Yes. I hire a scribe to offset time for patient discussions.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

On-shift. By asking them socratically how different parties, consultants, PMD’s, lawyers, and the patients themselves would interpret their documentation in the event that their diagnosis is correct…or if it was completely wrong.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

It’s a fine balance. Much like showing compassion and patient counseling, teaching is a corner that could be cut but I choose not to. I also preferentially pick up patients myself that are low yield so I do not need to spend time listening to presentations where I anticipate little teaching opportunity.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

As a life-long learner and a simulation lab director, I am continually developing my airway and procedural skills in general. I focus particularly on managing learners who are having challenges in completing procedures and this allows me to continue teaching, even when they are struggling while avoiding putting patients at risk.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

If the residency leadership team has identified a weakness during our monthly reviews, I make that weakness the goal of the shift. Otherwise, I try to huddle with the resident at the start of the shift to see what they have self-identified as a learning goal.

Do you typically see patients before or after they are presented to you?

After unless I “discover” an interesting patient of my own that I intended to see alone but is just so fascinating that I send the resident in redundantly.

How do you boost morale amongst learners on shift?

I like to both say the words and physically, “take a moment” and point out the countless great wins we have every day: recognition of subtle EKG changes, transforming a terrified patient into a calm one, early recognition and resuscitation of a deadly disease, and force them to not overlook the victories, that can so easily get overshadowed by the frustrations.

How do you provide learners feedback?

On shift, after shift, written and verbal.

Are there any resources you use regularly with learners to educate during a shift?

Up to Date, EM-RAP, and YouTube.

What are your three favorite topics to teach during a shift?

Difficult airways, excited delirium, and ultrasound of the hypotensive patient.

Who are three other educators you’d like to answer these questions?

Jerry Hoffman and Gary Greenwald

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Graham E. Snyder, MD, FACEP|2022-09-03T10:59:27-07:00Aug 31, 2022|How I Educate, Medical Education, Uncategorized|

Background

Direct-acting oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are widely used for various indications and considered first-line therapy for prevention of acute ischemic stroke in patients with nonvalvular atrial fibrillation [1]. The management of acute ischemic stroke in patients on DOACs presents a difficult clinical scenario in the emergency department due to concern for increased risk of hemorrhage. IV thrombolytics (e.g., alteplase, tenecteplase), a mainstay in acute ischemic stroke management, are not recommended in current guidelines for patients whose last DOAC dose was within the last 48 hours [2, 3]. Therefore, patients with an acute ischemic stroke who are compliant with their DOACs are often excluded from guideline recommended therapy. Additionally, as covered in a previous ALiEM post, it is not recommended to reverse anticoagulation status in order to administer a thrombolytic.

Evidence

The use of IV thrombolytics in patients on DOACs was evaluated by Kam et al in a 2022 study published in JAMA [4]. This retrospective analysis included 163,038 patients from the AHA/ASA Get With The Guidelines-Stroke registry with acute ischemic stroke who received IV alteplase within 4.5 hours of symptom onset. Of the total number of patients, only 2207 had documented use of a DOAC within the last 7 days, with 25 of these patients reporting DOAC use within 48 hours. Patients on warfarin or other anticoagulants were excluded. The primary outcome was symptomatic intracranial hemorrhage (ICH) within 36 hours of IV alteplase administration. After adjusting for clinical factors, the rate of symptomatic ICH was not significantly different between patients taking DOACs and those not on anticoagulation (3.7% vs. 3.2%, adjusted OR 0.88, 95% CI 0.70 to 1.10). However, when stratified based on time from last DOAC dose, patients who took their DOAC 0-48 hours prior had an 8% rate of symptomatic ICH compared to 3.2% among those not on DOACs. Furthermore, the rate of any alteplase complication was 12% vs. 6% in those taking DOACs within 48 hours vs. no DOAC.

Limitations

The population at highest risk for bleeding is patients who took a DOAC within the last 48 hours, and this study only included 25 such patients.
- A similar study tried to answer the same question for warfarin patients with an INR between 1.5-1.7. They also failed to include enough patients to make any definitive conclusions. [5]
Timing from the last DOAC dose was given as a range, with the majority of patients reporting use sometime within the last 7 days. It has been established in current AHA/ASA guidelines that receipt of DOACs past 48 hours prior is considered safe for thrombolytic administration, and if the included institutions were following current recommendations, thrombolytics were likely administered mostly to patients outside the 48-hour window.
Large potential for selection bias, since it was reported that almost 23,000 patients on DOACs from the original registry (who were otherwise eligible) did not receive thrombolytics.
Not clear how patients were determined to be on DOACs or if the authors were able to confirm this in unresponsive/intubated/deceased patients retrospectively. This could have resulted in DOAC patients being included in the non-DOAC group, which could have falsely evened-out the bleeding rates.

Bottom Line

The management of acute ischemic stroke in patients receiving prior anticoagulation presents a challenging clinical scenario.
Studies to date fail to include enough patients to evaluate the true risk of bleeding.
This study supports the current guideline recommendation to avoid alteplase in patients receiving a DOAC within 0-48 hours due to the increased risk of intracranial hemorrhage.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Published correction appears in Circulation. 2019;140(6):e285. Circulation. 2019;140(2):e125-e151. doi: 10.1161/CIR.0000000000000665. PMID: 30686041.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. PMID: 31662037.
Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021;6(1):I-LXII. doi: 10.1177/2396987321989865. PMID: 33817340.
Kam W, Holmes DN, Hernandez AF, et al. Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA. 2022;327(8):760-771. doi:10.1001/jama.2022.0948. doi: 10.1001/jama.2022.0948. PMID: 35143601.
Xian Y, Liang L, Smith EE, et al. Risks of intracranial hemorrhage among patients with acute ischemic stroke receiving warfarin and treated with intravenous tissue plasminogen activator. JAMA. 2012;307(24):2600-2608. doi:10.1001/jama.2012.6756. doi: 10.1001/jama.2012.6756. PMID: 22735429.

Primary author:

Jessica Mason, PharmD

PGY-2 Emergency Medicine Pharmacy Resident

Massachusetts General Hospital

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2022-03-18T08:03:52-07:00Apr 2, 2022|EM Pharmacy Pearls, Heme-Oncology, Neurology, Tox & Medications, Uncategorized|

Background

Nitroglycerin (NTG) is an important intervention to consider for patients with Sympathetic Crashing Acute Pulmonary Edema (SCAPE) as it significantly reduces preload, and even modestly reduces afterload with high doses. For acute pulmonary edema in the ED, NTG is often administered as an IV infusion and/or sublingual tablet. Starting the infusion at ≥ 100 mcg/min produces rapid effects in many patients and can be titrated higher as tolerated, with doses reaching 400 mcg/min or greater. Combined with noninvasive positive pressure ventilation (NIPPV) and in some cases IV enalaprilat, patients often turn around quickly, from the precipice of intubation to comfortably lying in bed [1, 2]. But what does the literature say about starting with a high-dose NTG IV bolus followed by an infusion?

Evidence

A 2021 prospective, pilot study of 25 SCAPE patients proposed a clear and systematic protocol (below) for treating these critically ill patients with a combination of high-dose NTG bolus (600 – 1000 mcg over 2 mins) followed by an infusion (100 mcg/min) and NIPPV [3].There were no cases of hypotension after the bolus and 24 of the 25 patients were able to avoid intubation. Additionally, an earlier PharmERToxGuy post summarizes some of the previous studies evaluating the use of a high-dose NTG IV bolus for acute pulmonary edema.

It is important to note that some institutions may not allow IV push NTG or may limit the use of NTG boluses. Providers may then opt to implement dosing strategies such as bolusing from an IV infusion pump or initiating the infusion at a high rate for a short period (e.g., NTG 300 mcg/min for 2-3 minutes) before reducing the rate to a more traditional infusion rate (e.g., 100 mcg/min).

Bottom Line

A few small ED studies support the use of an initial IV NTG bolus followed by an infusion compared to the infusion alone [1, 2]
There is a low risk of hypotension following a single IV NTG bolus
Consider using the following protocol to identify which doses may be best for specific patients based on initial systolic blood pressure

Click for full-sized version [3]

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med. 2020;38(1):132-137. doi: 10.1016/j.ajem.2019.06.046. PMID: 31327485.
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. PMID: 27825693.
Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-dose nitroglycerin bolus for sympathetic crashing acute pulmonary edema: a prospective observational pilot study. The Journal of Emergency Medicine. Published online June 2021:S0736467921004674. doi: 10.1016/j.jemermed.2021.05.011.

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2021-07-06T07:20:14-07:00Jul 10, 2021|EM Pharmacy Pearls, Pulmonary, Tox & Medications, Uncategorized|

Background

A previous ALiEM post from 2013 by an EM pharmacist colleague argued the case against one-time vancomycin doses in the ED prior to discharge. The take-home points from this post were:

No evidence that a one-time vancomycin has any benefit
This practice is not recommended by the Infectious Diseases Society of America (IDSA)
May extend the patient’s ED stay by at least an hour for the IV infusion, depending on the dose
Increases the cost of the ED visit (e.g., IV line, medication, RN time)
Pharmacokinetically 1 dose of vancomycin doesn’t make sense
Vancomycin 1 gm IV x1 provides sub-therapeutic levels for patients with normal renal function
Efficacy is based on overall exposure (e.g., AUC/MIC) achieved with repeated dosing over several days
Subtherapeutic vancomycin concentrations lead to development of resistance

Despite the above points, a one-time dose of vancomycin prior to the patient being discharged on an oral regimen is a common practice [1].

Evidence

As stated above, a single dose of vancomycin is unlikely to provide a therapeutic benefit and may only serve to reassure clinicians. The 2020 consensus guidelines regarding vancomycin monitoring for serious MRSA infections reinforce the recommendation of achieving an AUC_0-24/MIC ratio of ≥400, as a ratio <400 increases resistance and has inferior efficacy [2]. Since the AUC is dependent on overall time of exposure plus concentration, a single dose for an average patient with normal renal function is not adequate (Figure 1). The graph below also demonstrates how long it generally takes for vancomycin to reach steady state when patients receive a dose every 8 hours.

*The estimated AUC above assumes a 30 yo male that weights 70kg and is 6′ tall with a serum creatinine of 1.0 mg/dL.

A randomized trial conducted at Christiane Care Health System compared patients who received a vancomycin loading dose of 30 mg/kg or 15 mg/kg [3]. Just twelve hours after this initial dose, 34.6% of patients who received 30 mg/kg had vancomycin levels in the therapeutic range (trough >15 mg/L) vs. 3% of patients who received 15 mg/kg (p < 0.01).

Bottom Line

Even large vancomycin loading doses rarely achieve therapeutic levels after one dose. Therefore, if the plan is to discharge, skip the one-time dose altogether and choose an antimicrobial regimen that will be continued in the outpatient setting (e.g., doxycycline or sulfamethoxazole/trimethoprim if concerned for MRSA or cephalexin for most other patients).

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

Mueller K, McCammon C, Skrupky L, Fuller BM. Vancomycin use in patients discharged from the emergency department: a retrospective observational cohort study. J Emerg Med. 2015;49(1):50-57. doi: 10.1016/j.jemermed.2015.01.001. PMID: 25802166.
Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant staphylococcus aureus infections: a revised consensus guideline and review by the american society of health-system pharmacists, the infectious diseases society of america, the pediatric infectious diseases society, and the society of infectious diseases pharmacists. Am J Health Syst Pharm. 2020;77(11):835-864. doi: 10.1093/ajhp/zxaa036. PMID: 32191793.
Rosini JM, Laughner J, Levine BJ, Papas MA, Reinhardt JF, Jasani NB. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother. 2015;49(1):6-13. doi: 10.1177/1060028014556813. PMID: 25358330.

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2021-04-29T15:40:57-07:00May 1, 2021|EM Pharmacy Pearls, Infectious Disease, Tox & Medications, Uncategorized|

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