NCHD

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Medications
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Phones
Sepsis
Sepsis
NCHD.ie©2016 Dr. ÍOS

Settings

Welcome

Welcome

This NCHD guide is a small web app that will work off line once you have chosen your current hospital.

Please "add to home screen" and an icon link will be downloaded for future easy access.

You may be asked to permit future guideline or medication updates to reflect local protocols.

No personal data has or will be collected.

You are free (as in speech or beer) to use the app. in any local clinical environment.

Please take a moment to provide feedback (under settings on the home screen) when you get a chance.

Slán, Íomhar

NCHD.ie©2016 Dr. ÍOS

Acknowledgements

Thank you


We would like to thank a number of people who made this app. possible.

Fiona Ahern (pharmacist Cork University Hospital), Frank O'Riordan (antibiotic pharmacist, Mercy University Hospital, SIVUH), Mala Shah and Paula Murphy (pharmacists, CUH), who work tirelessly to ensure the medication / antimicrobial guidelines are correct and up to date. Many thanks to Dr. Sile O'Connor for her work in preparing the BSH Tralee antibiotic guidelines.

Ms. Terri Goulding, for her fantastic organisation and dedication to NCHD training/education in CUH.

The Cork & Kerry Infection Control Committee kindly provided funding for a laptop to enable development of the mobile application.

For more comprehensive clinical guidelines please visit EMed.ie.

We would like to give a special Thank You to Dr. Tim Keady (Intern in CUH 2014), Dr. Nick Barrett, Anaesthetic Reg., Dr. Dominic Hegarty, Pain Specialist, and Marih O'Leary, Pharmacist, for the Analgesia Ladder (Adults) information.

Dr. Íomhar O' Sullivan.
Consultant in Emergency Medicine, Cork.


Disclaimer

The antimicrobial information contained in this App was collated by the Cork Kerry antimicrobial stewardship sub-committee and reflect the antimicrobial guidelines of the (CUH, MUH, SIVUH and Bon Secours hospitals in Tralee & Cork). Therefore use of this app by any persons including health professionals working within other hospitals, is at your own risk, and we make no representations or guarantees as to the adequacy or completeness of any of the information contained in this app, or the app’s compatibility with any policies or procedures of other hospitals, where the app is used by persons other than healthcare professionals working within the CK hospitals.

This app is intended as a support tool for health professionals working within CK hospitals and is provided for reference only. It does not take into account the individual circumstance of a patient and may not contain all the information you require. It should therefore not be used as the sole basis for prescribing any drugs or for the care of any patient. While every attempt has been made to ensure the accuracy of the content, doctors and other healthcare professionals should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient.

References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). The interpretation and application of the guidelines remains the responsibility of the individual clinician. Please seek advice if in doubt.

Updates may be released periodically and it is the responsibility of the user that they have the most up to date version available. This is available on the hospital Intranet.

NCHD.ie©2016 Dr. ÍOS

Hospital

NCHD.ie©2016 Dr. ÍOS

Phone No.s

Phone List

NCHD.ie©2016 Dr. ÍOS

Phone No.s

Phone List

NCHD.ie©2016 Dr. ÍOS

IT system

Checking the directory:

Log on to ‘HSE staff directory’ icon which is on most computers. The following screen will appear and it is self explanatory. When on call, make sure you have the right date. Also, note the ‘liaison psych consultation’ icon in the top left of the screen.

logon screen

Using PIMS:

Most interns will have to print off lists of in-patients each day as well as having patient stickers available. Log into you Citrix 4.5 account and click on the PIMS icon. The following screen will then appear. The four main buttons are identified in the diagram.

drill down

  1. To look up a patient’s details and past history click button 1 and follow the links.
  2. To PRINT a list of in-patients, click button 3 and click OK. When the list appears, press F2 to print.

ward or patient view

  1. You need to ring IT to get your list changed to a different consultant every time you change jobs. They’ve cracked down on this for data protection purposes, there are no longer any generic passwords and you can only print your own consultants list.
  2. To print stickers, click button 2 and enter the ward that the patient is on. Right click on the patient’s name and select ‘labels and front-sheets’ from the options. Untick front-sheet. The following screen will follow. Click OK to print. Make sure that the small labels are in the printer.

results

NCHD.ie©2016 Dr. ÍOS

Microbiology

Microbiology section

These guidelines are for adults only. For pregnancy/breastfeeding guidelines please change your hospital to CUMH.

These .


©CKICC 2016 Dr. ÍOS

Microbiology

Microbiology section

These guidelines are for CUMH patients only. For general hospital patients please change your hospital to CUH.

These .

Before prescribing any antibiotics, please read this advice.


©CKICC 2016 Dr. ÍOS

Header

©CKICC 2016 Dr. ÍOS

Aspiration pneumonia

Aspiration pneumonia

©CKICC 2016 Dr. ÍOS

Cardiac

Cardiac section

©CKICC 2016 Dr. ÍOS

CURB-65

CURB-65 score

For estimating severity / prognosis in community acquired pneumonia.

CURB-65 score
Symptom Score
Confusion 1
Urea > 7 mmol/l 1
Resp rate >30 1
SBP<90 or DBP<60 mmHg 1
Age ≥ 65 1

Risk of death at 30 days

Predicted mortality
Score Risk RIP
0 <1%
1 3%
2 13%
3 17%
4 42%
5 57%

CURB-65 also good predictor of mortality with ANY infection (not just pneumonia).


General management advice
CURB-65 Advice
0 - 1 Treat as out-patient
2 Consider a short stay in hospital or watch closely as an outpatient
3-5 Requires admission +/- ITU
©CKICC 2016 Dr. ÍOS

ENT

ENT section

©CKICC 2016 Dr. ÍOS

Gastrointestinal

Gastrointestinal section

©CKICC 2016 Dr. ÍOS

Genitourinary

Genitourinary section

©CKICC 2016 Dr. ÍOS

Neurological

Neurological section

©CKICC 2016 Dr. ÍOS

Ophthalmology

Ophthalmology section

©CKICC 2016 Dr. ÍOS

Respiratory

Respiratory section

©CKICC 2016 Dr. ÍOS

Soft Tissue/ Bone

Soft tissue and bone section

©CKICC 2016 Dr. ÍOS

Sepsis

Sepsis section



©CKICC 2016 Dr. ÍOS

Sepsis-Six

Emergency Medicine Programme

Please approach in the chronological order as below and tick each positive item.


1. Infection suspected

2. SIRS criteria

Or at least two or more SIRS

3. Sepsis 6 (within 1 hour)

Take

  • Bld cultures (2 sites before antibiotics if possible)
  • Check venous lactate and Hb
  • Monitor Urine Output(±catheter)

Give

  • O2 (94-98% SpO2 or 88-92% in Chronic Lung Disease)
  • Fluid (500ml bolus - up to 30ml/kg) & reassess. Target SBP>100/MAP>65. Monitor response to IV fluids and titrate to effect
  • Give IV antibiotics

Lab tests available and acted upon within an hour.

4. Look for organ dysfunction

5. Look for septic shock (post fluid bolus)

NCHD.ie©2016 Dr. ÍOS

SIRS

SIRS - Systemic inflam. response syndrome

Two or more of :

Sepsis

SIRS and documented infection (culture or gram stain of blood, sputum, urine or normally sterile body fluid positive for pathogenic micro-organism; or focus of infection identified by visual inspection). More and management on EMed.ie.

Severe sepsis

Sepsis and at least one sign of organ hypoperfusion or organ dysfunction:

More and management on EMed.ie.

Septic shock

Severe sepsis and one of:

More and management on EMed.ie.

©CKICC 2016 Dr. ÍOS

Systems

Anatomical systems

©CKICC 2016 Dr. ÍOS

Viral Infections

©CKICC 2016 Dr. ÍOS

Fungal Infections

©CKICC 2016 Dr. ÍOS

Gynaecology

Gynaecology antimicrobials

©CKICC 2016 Dr. ÍOS

Pregnancy

Infections in pregnancy

©CKICC 2016 Dr. ÍOS

Wound infection (pregnancy)

Pregnancy wound infections

©CKICC 2016 Dr. ÍOS

Prophylaxis (in pregnancy)

Pregnancy antibiotic prophylaxis

©CKICC 2016 Dr. ÍOS

Viral infection (pregnancy)

Pregnancy viral infections

©CKICC 2016 Dr. ÍOS

Fungal infection (pregnancy)

Pregnancy fungal infections

©CKICC 2016 Dr. ÍOS

Bacterial infection (pregnancy)

Pregnancy - bacterial infections

©CKICC 2016 Dr. ÍOS

Parasitic infection (pregnancy)

Pregnancy parasitic infections

©CKICC 2016 Dr. ÍOS

Antimicrobials in pregnancy & lactation

Antimicrobials in pregnancy & lactation

    
        

Aminoglycosides

    
Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Gentamicin Low risk Compatible Developmental toxicity has not been associated with gentamicin. Due to the limited available data and the theoretical toxicity risks, gentamicin use in pregnancy is generally reserved for serious/ life threatening infections where standard antibiotic therapy has not been effective.
        

Antifungals/antivirals

    
Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Fluconazole Risk (≥400mg/day). Discuss with Pharmacy if considering treatment Compatible Reports of teratogenicity with Fluconazole at continuous daily doses of 400mg/day or more in the 1st trimester. Risk of adverse outcomes appears low with lower doses. A low, single oral dose of Fluconazole during pregnancy is unlikely to pose a substantial teratogenic risk, but the data are insufficient to state that there is no risk.
Aciclovir
Valaciclovir
Compatible Compatible
Oseltamivir Compatible Compatible Maternal benefit far outweighs the unknown risk, if any, to the foetus.
        

Cephalosporins

  
Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Cefalexin Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.
Ceftriaxone Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.
Cefuroxime Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.
        

Penicillins

  
Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Benzylpenicillin Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Flucloxacillin Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Amoxicillin Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Co-amoxiclav Compatible No human data (for clavulanic) probably compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Piptazobactam Animal data suggests low risk Probably compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Meropenem Animal data suggest low risk Probably compatible
        

Macrolides

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Azithromycin Animal data suggest low risk Probably compatible Limited human data do not suggest risk of developmental toxicity with Azithromycin. Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.
Clarithromycin Animal data suggest high risk Probably compatible Animal data with clarithromycin suggest risk but human pregnancy experience suggests the risk, if it exists, is low. Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.
Erythromycin Compatible Compatible Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.
        

Quinolones

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Ciprofloxacin Human data suggest low risk. Discuss with Pharmacy if considering treatment Potential toxicity The use of ciprofloxacin during human gestation does not appear to be associated with an increased risk of major congential malformations.
Briggs: "Although a number of birth defects have occurred in the offspring of women who had taken ciprofloxacin, the lack of a pattern to these anomalies is considered reassuring. Other authors consider fluoroquinolones to be contraindicated in pregnancy due to animal studies."
Fluoroquinolones have traditionally not been used in nursing mothers due to concerns about adverse effects on the infants' developing joints. However, recent studies indicate little risk.
Ofloxacin Human data suggest low risk. Discuss with Pharmacy if considering treatment Probable compatible Use with caution in 1st trimester.
Although a number of birth defects have occurred in the offspring of women who had taken ofloxacin, the lack of a pattern to these anomalies is considered reassuring.
Fluoroquinolones have traditionally not been used in nursing mothers due to concerns about adverse effects on the infants' developing joints. However, recent studies indicate little risk.
    
        

Tetracyclines

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Doxycycline Contraindicated in 2nd and 3rd trimester Compatible BNF: "Doxycycline may be used for malaria prophylaxis if other regimens are unsuitable, and if the entire course of doxycycline is completed before 15 weeks' gestation".
Contact Infectious Diseases/ Pharmacy if 1st trimester treatment being considered.
Unlike to cause harmful effects in breastfeeding infants if short-term use. Avoid prolonged or repeat courses during nursing.
Theoretical risk of dental staining and decreased bone growth in infant. However, risk appears remote (drug levels in breast milk undetectable).
Monitor the infant for rash and for possible effects on the gastrointestinal flora, such as diarrhoea or thrush.
        

Miscellaneous

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding
Clindamycin Compatible Compatible Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea or candidiasis.
Mebendazole Low risk Probably compatibel; Avoid in 1st trimester Mebendazole is poorly absorbed from the GI tract.
Metronidazole Low risk Potential toxicity
Discuss with pharmacy if considering.
Avoid in 1st trimester With maternal intravenous and oral therapy, breastfed infants receive metronidazole in doses that are less than those used to treat infections in infants, although the active metabolite adds to the total infant exposure.
Case reports of candida infections and diarrhoea have been reported.
Mupirocin
(nasal)
Probably compatible Probably compatible 1% of mupirocin is absorbed after topical application. Considered to be low risk to the nursing infant.
Nitrofurantoin Risk in 3rd triemster Probably compatible but
Avoid first 8 days of life.
Theoretical risk of neonatal haemolytic anaemia if used in last few weeks of pregnancy. If nitrofurantoin treatment indicated in nursing mother, start after the first week of life (risk of haemolytic anaemia greater).
Permethrin
(topical)
Compatible Compatible
Vancomycin Compatible Probably compatible Only low levels secreted into breast milk. Poor oral absorption.
Monitor infant for possible effects on gastrointestinal flora, such as diarrhoea.
Guide©2016 Dr. ÍOS

Antimicrobials in pregnancy and lactation

Categorisation of Drug Risk in Pregnancy and Lactation

Previous versions of the CUMH Antimicrobial Guideline used the FDA (Food and Drug Administration) pregnancy labelling categories A, B, C, D and X to categorise risk in pregnancy. The FDA have discontinued using this nomenclature, due to limitations of the system including:

For the purposes of this guideline, the Briggs Classification has been adapted for assessing risk in pregnancy and lactation.

In pregnancy

In lactation

The decision to administer a drug to a nursing mother should only be made after assessing the risks and the benefits to both the mother and nursing infant.

Several factors should be considered prior to prescribing:

  1. The need for maternal treatment and the drug choice.
  2. The age and maturity of the baby - liver and kidney systems do not work fully for some time after birth. Premature babies are particularly susceptible to drugs and may exhibit higher than expected drug levels.
  3. The volume of breastmilk being taken daily - a fully fed two-week-old baby consumes more milk than a nine-month-old feeding just once or twice a day.

Briggs classification of risk in pregnancy

Compatible

The human pregnancy experience, either for the drug itself or drugs of the same class or with similar mechanisms of action, is adequate to demonstrate that the embryo-foetal risk is very low or nonexistent. Animal reproductive data are not relevant.

Limited human data - probably compatible

There may or may not be human pregnancy experience, but the characteristics of the drug suggest that it does not represent a significant risk to embryo-foetus. For example other drugs in the same class or with similar mechanisms are compatible or the drug does not obtain significant systemic concentrations. Any animal reproductive data are not relevant.

Human data suggests low risk

There is limited human pregnancy experience, either for the drug itself or drugs of the same class or with similar mechanisms of action, including the 1st trimester, suggesting that the drug does not represent a significant risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) at any time in the pregnancy. The human pregnancy data outweigh any animal reproductive data.

Risk in 3rd trimester

Evidence (for the drug or similar drugs) suggests that there may be a foetal risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) in the 3rd trimester, or close to delivery, but not in the 1st or 2nd trimesters. The human pregnancy data outweigh any animal reproductive data.

Contraindicated in 2nd and 3rd trimester

Human exposures in the 2nd and 3rd trimesters, either to the drug itself or to the drugs in the same class or with similar mechanisms of action, have been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug should not be used in the 2nd and 3rd trimesters.

Limited human data - animal data suggest low risk

Either there is no human pregnancy experience or few pregnancy exposures have not been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug does not cause developmental toxicity (at doses that did not cause maternal toxicity) in all animal species studied at doses ≤ 10 times the human dose based on body surface are (BSA) or AUC.

Human data suggest risk

The human data for the drug or drugs in the same class or with the same mechanism of action, and animal reproduction data if available, suggest there may be a risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) throughout the pregnancy. Usually, pregnancy exposure should be avoided, but the risk may be acceptable if the maternal condition requires the drug.

Limited human data - suggest high risk

Either there is no human pregnancy experience or few pregnancy exposures have not been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug causes developmental toxicity (at doses that did not cause maternal toxicity) in three or more animal species at doses ≤10 times the human dose based on body surface are (BSA) or AUC.

Briggs classification of risk in breastfeeding

Compatible

Either the drug is not excreted in clinically significant amounts into human breast milk or its use during lactation does not, or is not expected to, cause toxicity in a nursing infant.

Limited human data - probably compatible

Either there is no human data or the human data are limited. The available data suggest that the drug does not represent a significant risk to a nursing infant.

Limited human data suggests toxicity

Either there is no human data or the human data are limited. The characteristics of the drug suggest that it could represent a clinically significant risk to a nursing infant. Breastfeeding is not recommended.

Guide©2016 Dr. ÍOS

Prophylaxis

Prophylaxis

NCHD.ie©2016 Dr. ÍOS

Prophylaxis-Endocarditis

Endocarditis prophylaxis is only recommended in the situations detailed below, as antibiotic prophylaxis may only be effective at preventing a very small number of endocarditis cases. Infective endocarditis is much more likely to be caused by frequent exposure to random bacteraemias than bacteraemias caused by dental, GI tract or GU tract procedures. The risk of antibiotic-related adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

Maintenance of optimal oral health and hygiene is important in reducing the risk of endocarditis from dental procedures

Cardiac conditions that require endocarditis prophylaxis:

Dental procedures:

Endocarditis prophylaxis recommended only in patients with the above cardiac conditions, for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa.

Endocarditis prophylaxis NOT recommended for the following:


For Dental procedures:

Given single dose 30-60 min. prior to procedure:
1st line option In penicillin allergy
Adults: Amoxicillin 2 grams po/iv Adults: Clindamycin 600mg po/iv

GI tract or GU tract procedures:

Endocarditis prophylaxis not recommended.

Respiratory procedures:

Endocarditis prophylaxis is only recommended in patients with the above cardiac conditions for patients undergoing the following:

NB: if the infection is known to be caused by S. aureus, use Flucloxacillin 1g po / iv single dose for prophylaxis. If caused by MRSA or penicillin allergic, use vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

Infected skin, skin structure and musculoskeletal tissue:

Endocarditis prophylaxis is only recommended in patients undergoing surgical procedures with the above cardiac conditions.

Flucloxacillin 1g iv / po should be given 30-60 mins prior to procedure.

If MRSA or penicillin allergic: give vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

NCHD.ie©2016 Dr. ÍOS

Prophylaxis-Meningitis

Prophylaxis-Meningitis

Bacterial meningitis is a notifiable disease. Inform Public Health: Tel.: 021 4927601 or out of hours through ambulance service 021 4921114. Public Health will advise on chemoprophylaxis of contacts.

Meningococcal Infection

Adults and children >12 years 1st line: Rifampicin 600mg every 12 hours for 4 doses.
Alternative: Ciprofloxacin 500mg po stat.
Female adults on the oral contraceptive pill Ciprofloxacin 500mg po stat
Pregnant women Ceftriaxone 250mg im stat
Children: 1-12 years 1st line: Rifampicin 10mg/kg (max. 600mg) every 12 hours for 4 doses.
Alternativen: only for children >2 years.
2-5 years: Ciprofloxacin 125mg po stat.
5-12 years: Ciprofloxacin 250mg po stat.
Infant <1 year Rifampicin syrup 5mg/kg every 12 hours for 4 doses

Haemophilus influenzae type b (Hib) infection

Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received Ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.

Adults Rifampicin 600mg once daily for 4 days
Child:1-12yrs Rifampicin 20mg/kg (max 600mg) once daily for 4 days
Infant:<1 yr Rifampicin syrup 10mg/kg once daily for 4 days
Pregnant women Not indicated

Notes on Rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after Rifampicin treatment. If on other drugs, check BNF, product data sheets on www.medicines.ie / consult pharmacy regarding drug interactions with Rifampicin

Vaccination
If Neisseria meningitidis Groups B, C, A, Y, W, 135 vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
If Haemophilus influenzae type b or pneumococcal meningitis: vaccination of contacts and index may be indicated. Please refer to Public Health for advice.

NCHD.ie©2016 Dr. ÍOS

Surgical
Prophylaxis Principles

Principles of surgical prophylaxis

  1. Prophylaxis should be given within 60 minutes prior to surgical incision. Please note that certain antibiotics (e.g. vancomycin, gentamicin 5mg/kg, clindamycin and metronidazole) cannot be given as bolus injections. It is important that the infusions are completed before incision. Reduce gentamicin dose to 3mg/kg iv if CrCl <30ml/min.
  2. Always check previous microbiology cultures and sensitivities (MC&S) to guide choice of antibiotic for surgical prophylaxis. Consult micro. If recent Hx of MRSA, vancomycin should be given as part of surgical prophylaxis.
  3. Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit.
  4. An additional peri-operative prophylactic dose should be considered by the surgeon for procedures lasting >4 hours for cefuroxime and co-amoxiclav, or if there is blood loss >1500ml or haemodilution >15ml/kg
  5. Post operative doses of antibiotics will further disturb normal microbiological flora and increase the risk of Clostridium difficile. Only use post-operative antibiotics if specifically advised in the guideline or the patient requires treatment of infection (e.g. peritonitis post- perforated appendicitis).
  6. Clean surgery is associated with a low risk of infection and there is usually no indication for surgical antibiotic prophylaxis.
NCHD.ie©2016 Dr. ÍOS

Prophylaxis-Splenectomy

Prophylaxis-Post Splenectomy

Please refer to local Intranet staff directory or NCHD.ie/asplenic.html (internet access required)..

NCHD.ie©2016 Dr. ÍOS

Surgical
Prophylaxis

List of procedures requiring antibiotic prophylaxis is not exhaustive.

NCHD.ie©2016 Dr. ÍOS

Appendix 1

CUMH Surg. prophylaxis

Indications

Surgical antibiotic prophylaxis is recommended for the following procedures:

Surgical prophylaxis is not routinely necessary for other laparoscopic procedures, minor operations or diagnostic hysteroscopies.

Timing

Antibiotic prophylaxis should be started ideally within 60 minutes prior to incision for all surgery, including Caesarean section.

Ensure that the antibiotic prophylaxis administered is documented.

Additional doses

Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit.

An additional peri-operative prophylactic dose should only be considered by the surgeon for:

If clinical findings are suggestive of infection, a course of appropriate antimicrobial treatment should be prescribed.

Surgical prophylaxis for C-section

Single dose Cefuroxime 1.5g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg iv (Max dose 480mg), within 60 minutes prior to incision.

Surgical prophylaxis excluding C-section

Single dose Co-amoxiclav 1.2g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg IV (Max dose 480mg), within 60 minutes prior to incision.

Endocarditis prophylaxis

No longer indicated for vaginal deliveries. Refer to appropriate surgical prophylaxis protocol if undergoing surgery.

MRSA

If recent history of MRSA colonisation, vancomycin 15mg/kg should be given as part of surgical prophylaxis. See Vancomycin dosing, administration and monitoring.

Guide©2016 Dr. ÍOS

Prescribe Tips

Prescribing tips

Antimicrobials

NCHD.ie©2016 Dr. ÍOS

Amikacin dosing

Amikacin dosing

Once daily dosing

Once daily dose

Not for endocarditis, febrile neutropenia or meningitis.

15mg/kg q24h iv.

Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.

Correct dose in obesity below.

Adjustment in renal impairment below.

Administration

iv infusion: Dilute in 100ml sodium chloride 0.9% and adsminister over 30-60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Reference range

Pre-dose (trough) level ≤5mg/L.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Twice daily dosing

Twice daily dosing

7.5 mg/kg q12h iv
(can be increased in severe infections to 7.5 mg/kg q8h).

Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.

Correct dose in obesity as below.

Adjustment in renal impairment - see below.

Administration

iv bolus over 32-3 minutes or (preferred): dulute to 2.5mg/ml with 0.9% NaCl and admin. over 30 mins.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose

Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤10mg/L
Post dose level (peak) ≤ 30mg/L (aim for 20-30mg/L)

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Amikacin dosing
GFR 20-50ml/min: GFR 10-30ml/min: GFR <10ml/min:

CAPD: Dose as per <10ml/min.
HD: 5mg/kg after dialysis
Give dose after dialysis.
CVVH: 7.5mg/kg q24h, as per levels

10mg/kg q24h

3-4mg/kg q24h

2mg/kg q24h-q48h

NCHD.ie©2016 Dr. ÍOS

CDAD

Clostridium Difficile assoc. Diarrhoea

Antibiotic Associated Diarrhoea (AAD) occurs in association with the administration of antibiotics. The spectrum of findings ranges from colitis to so-called 'nuisance' diarrhoea. Infection with Clostridium difficile (CDI) accounts for only 10 to 20% of the cases of AAD, but it accounts for the majority of cases of colitis. Major risk factors for C. difficile infection include: advanced age, hospitalisation, exposure to antibiotics.

Some antibiotics are frequently implicated in C. difficile associated diarrhoea (CDAD) – e.g. Cephalosporins, Clindamycin, Quinolones and broad spectrum antibiotics, but virtually any antibiotic may be implicated, including brief courses e.g. surgical prophylaxis. Occasional cases follow treatment with Methotrexate or Paclitaxel (chemotherapy treatments of cancer).

Definition of Clostridium Difficile Associated Diarrhoea (CDAD):

Patient with ≥1 of:

Classification of CDAD

Mild to moderate CDI

Has no features of severe CDI.

Severe CDI (any of):

Severe, complicated CDI:

Severe disease with ↓BP, shock, ↑lactate, ileus or mega colon.

Diagnosis

Refer to local microbiology laboratory for testing procedures. Testing of asymptomatic individuals is not recommended.

General Mx


NCHD.ie©2016 Dr. ÍOS

CDAD 1st episode

CDAD - First episode

Mild to moderate CDI:

Severe CDI: (by any of following)

Management

Severe, complicated CDI:

Management

* Fidaxomicin has not been tested in pregnant or breastfeeding women or in patients with a history of inflammatory bowel disease.

Oral Vancomycin preparation for inpatients:

The solution will be best prepared immediately before use, as there is no preservative. Sterile Water for injection may be used to prepare the solution, as Vancomycin hydrochloride is freely soluble in water and also to try and maintain an aseptic as possible environment.

Using the 500mg vial to prepare the oral solution: Add 10ml water to the vial and withdraw 2.5ml in order to achieve 125mg.

After this initial reconstitution of the vial, the selected dose may be diluted in 30ml of water and given to the patient to drink or it may be administered in a naso-gastric tube if necessary.

Storage: Store the reconstituted injection in the fridge for no more than 24 hours and the date and time the vial was reconstituted should be clearly marked.

Patients discharged on oral vancomcyin: Oral capsules (125mg strength) are available in the community, on the Hi-Tech scheme.

NCHD.ie©2016 Dr. ÍOS

CDAD recurrent episode

CDAD - Recurrent episode

For first episode / first recurrence please see CDAD 1st episode.

Mx of 2nd & subsequent episodes of CDI.

Mild-moderate CDI:

Management of 2nd and subsequent episodes of recurrent CDI - Severe or severe/complicated CDI:

Treat as CDAD 1st episode

Oral Vancomycin preparation for in-patients

The solution will be best prepared immediately before use, as there is no preservative. Sterile Water for injection may be used to prepare the solution, as Vancomycin hydrochloride is freely soluble in water and also to try and maintain an aseptic as possible environment.

Using the 500mg vial to prepare the oral solution; Add 10ml water to the vial and withdraw 2.5ml in order to achieve 125mg. After this initial reconstitution of the vial, the selected dose may be diluted in 30ml of water and given to the patient to drink or it may be administered in a naso-gastric tube if necessary.

Storage: Store the reconstituted injection in the fridge for no more than 24 hours and the date and time the vial was reconstituted should be clearly marked.

Patients discharged on oral vancomcyin: Oral capsules (125mg strength) are available in the community, on the Hi-Tech scheme.

NCHD.ie©2016 Dr. ÍOS

CDAD Intra-colic Vancomycin

Intra-colic Vancomycin

For microbiologist supervision only.

Method

Dose adjustments may be required depending on individual circumstance including extent of colonic disease and patient weight. Vancomycin can be absorbed through inflamed colonic mucosa and cause toxicity if it accumulates in patients with renal failure.

Treat as CDAD 1st episode

NCHD.ie©2016 Dr. ÍOS

Gentamicin

Gentamicin dosing

Once daily dosing

Once daily dose

5mg/kg q24h iv (30-60 minutes), maximum 480mg in 24 hours.

Correct dose in obesity below.

In pregnancy please use booking weight.

Administration

In 100ml sodium chloride 0.9% over 30-60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Reference range

Pre-dose level ≤1mg/L.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).


More on Tobramycin and Amikacin monitoring.

Multiple daily dosing

Multiple daily dosing

tds for meningitis, extensive burns (1 – 1.7mg/kg q8h iv)
bd for endocarditis (1mg/kg q12h)
max 480mg in 24 hrs

Pregnancy: refer to CUMH antibiotic guidelines.

Correct dose in obesity.

Administration

iv bolus over 3-5 minutes or infuse in 100ml sodium chloride 0.9% over 30 minutes.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose
Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-10mg/L
Endocarditis pre-dose level ≤1mg/L
Endocarditis post dose level 3-5mg/L

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).


More on Tobramycin and Amikacin monitoring.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Gentamicin Once daily dosing
GFR 30-50ml/min: GFR 10-30ml/min: GFR 5-10ml/min:
3-5mg/kg q24h 3mg/kg q24h 3mg/kg and re-dose when level ≤1mg/L
Use with caution in renal impairment. Discuss with micro./pharmacy. Monitor serum gentamicin levels daily and dose accordingly.
  • Gentamicin calculator
  • Gentamicin Multiple daily dosing
    GFR 30-70ml/min: GFR 10-30ml/min: GFR 5-10ml/min:
    80mg q12h (60mg if <60kg) 80mg q24h (60mg if <60kg) 80mh q48h (60mg if <60kg)
    Use with caution in renal impairment. Discuss with micro./pharmacy. Monitor serum gentamicin levels daily and dose accordingly.
NCHD.ie©2016 Dr. ÍOS

MRSA

MRSA

MRSA is resistant to all β-lactam antibiotics including flucloxacillin. MRSA varies in its sensitivity to other antibiotics but is almost always sensitive to glycopeptides (i.e. Vancomycin and Teicoplanin).

MRSA colonisation/carriage

MRSA may be present at superficial sites without causing clinical signs of infection. This is termed colonisation or carriage. Topical antiseptics may be used to eradicate / reduce MRSA carriage. Please refer to the Infection Control Guidelines for full details on screening and eradication of MRSA. Prescribe Naseptin® on the patient’s MRS.

MRSA colonisation eradication(↓) regimen - 7 days

More detals on Infection Control Guidelines.

  1. Apply a small amount of 2% Mupirocin (Bactroban®) nasal ointment using a cotton bud to each nostril q8h. (Use Naseptin® cream, if Bactroban® unavailable)
  2. Use chlorhexidine gluconate 4% as a body wash in place of soap daily.
  3. Wash hair twice a week with chlorhexidine gluconate 4%.
  4. Apply chlorhexidine CX® powder to groin and axilla daily.
  5. Wash teeth / dentures with "Colgate Total" toothpaste (individual patient use) twice daily.
  6. Use chlorhexidine mouth wash twice daily if throat carriage is suspected.

Systemic treatment of MRSA with antibiotics should only be initiated if there are clinical signs of infection. If a patient who is colonised with MRSA develops an infection usually caused by staphylococci, it is likely that MRSA is the causative pathogen and this should be considered when treating the patient empirically.

Empirical/targeted regimens

Seek advice from Micro./I.D. regarding choice of agent and duration of treatment.

Surgical antibiotic prophylaxis

Patients who require surgery and have a history of MRSA colonisation or infection without documented eradication, or those who are at a high risk of MRSA colonisation should receive glycopeptide prophylaxis alone or in combination with other antibiotics active against other potential pathogens.

The use of glycopeptides may also be considered if there is an appreciable risk that patients’ MRSA carriage may have recurred or they come from facilities with a high prevalence of MRSA.

Glycopeptide antibiotics are recommended for surgical prophylaxis, administration to be completed within 60 minutes prior to incision: Vancomycin 15mg/kg iv. Refer to surgical prophylaxis guidelines for further detail.

MRSA practice points

©CKICC 2016 Dr. ÍOS

Penicillin Allergy

Penicillin allergy

All drug allergies must be specified on medication charts (with patient’s reaction).

In TRUE penicillin allergy*: ALL penicillins, cephalosporins and other beta lactam antibiotics should be avoided.

*TRUE penicillin allergy includes anaphylaxis, urticaria or rash immediately after penicillin administration.

In cases of intolerance to penicillin (e.g. GI upset) or rash occurring >72 hrs after administration, penicillins / related antibiotics should not be withheld unnecessarily in severe infection, but the patient must be monitored closely after administration.

If in doubt, seek advice from Microbiology or Pharmacy.

AVOID in Penicillin allergy:

Amoxicillin, Ampicillin, Flucloxacillin, Benzylpenicillin, Co-amoxiclav (e.g. Augmentin®/ Pinaclav®), Phenoxymethylpenicillin (Calvapen®), Piperacillin-tazobactam (Tazocin®), Extencilline®, Temocillin (Negaban®), Ticarcillin (Timentin®).

CAUTION in in Penicillin allergy:

Cephalosporins: Cefaclor, Cefadroxil, Cefalexin (Keflex®), Cefamandole, Cefazolin, Cefixime (Suprax®), Cefotaxime (Claforan®), Cefpodoxime, Ceftazidime (Fortum®), Ceftriaxone (Rocephin®), Cefuroxime (Zinacef®), Other beta lactam antibiotics: Aztreonam, Imipenem (Primaxin®), Meropenem, Ertapenem, Doripenem.

SAFE in Penicillin allergy:

Amikacin, Metronidazole, Ciprofloxacin, Moxifloxacin, Clarithromycin, Nitrofurantoin, Clindamycin, Rifampicin, Colistin, Sodium fusidate, Doxycycline, Teicoplanin, Erythromycin, Tobramycin, Gentamicin, Trimethoprim, Linezolid, Vancomycin.

©CKICC 2016 Dr. ÍOS

Renal dosing

Antimicrobial dosing in renal compromise

A (antimicrobial agent)

B - C

D - F

G - L

M - R

T - V

©CKICC 2016 Dr. ÍOS

Tobramycin dosing

Tobramycin dosing

Once daily dosing

Once daily dose

Not for endocarditis, meningitis or extensive burns.

5mg/kg q24h iv, maximum 480mg in 24 hours.

Correct dose in obesity below.

Administration

In 100ml sodium chloride 0.9% over 60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Multiple daily dosing

Multiple daily dosing

1 - 1.7 mg/kg q8h iv, max 480mg in 24 hours

Correct dose in obesity as below.

IOS - CHECK LINK TO RENAL DOSING

Administration

iv bolus over 3-5 minutes or infuse in 50-100ml sodium chloride 0.9% over 20-60 minutes.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose

Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-12mg/L

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Tobramycin Once daily dosing
GFR 20-50ml/min: GFR 10-30ml/min: GFR <10ml/min:

CAPD/HD: Dose as per <10ml/min.
HD: Give dose after dialysis.
Monitor levels daily and adjust dose accordingly.
CVVH: 2mg/kg q24h, according to levels

Give 1-2mg/kg then dose according to serum levels

Give 1mg/kg then dose according to serum levels

Give 1mg/kg then dose according to serum levels

NCHD.ie©2016 Dr. ÍOS

Vancomycin

Vancomycin levels are monitored to ensure efficacy and to minimise toxicity (mainly nephrotoxicity and ototoxicity)

Step 1 - Give ONE Loading Dose to all patients

Give one loading dose 25mg/kg (max 2g) to all patients.

Infusion rate: max 10mg/kg to avoid infusion-related reactions (incl. "red man" syndrome).

Infusion vol.: Dilute each 500mg in al least 100 ml 0.9% saline.

Step 2 - Maintenance Dose

In normal renal function : 15mg/kg IV every 12 hours at 10am and 10pm

In renal impairment (after loading dose given)

Creatinine Clearance Vanc. dose
>50ml/min15mg/kg q12h (to start 12 hours after loading dose)
20-50ml/min15mg/kg q24h (to start 24 hours after loading dose)
<20ml/min or haemodialysis15mg/kg & re-dose once level <20mg/L

Step 3- Monitoring levels

Send blood to microbiology, with the following information

Target pre-dose (trough) level: 10-20mg/L

Step 4 - Suggested vancomycin dose adjustments

Ensure level taken at the correct time, i.e. within two hours of next dose (preferably just prior to next dose)

Pre-dose (trough) levelSuggested dose alteration
<10mg/L

↑ each dose by 250mg-500mg.

If dose exceeds 2g bd, seek advice from micro./pharmacy regarding dosing strategies.

10-15mg/L

Desired range 10-20mg/L: no change
Desired range 15-20mg/L: ↑ each dose by 250mg

Max single dose is 2g. If total dose to exceed 2g q12h, contact pharmacy/micro for advice.

15-20mg/LNo change
>20mg/LOmit next dose(s) until level <20mg/L and then reduce each dose by 500mg
NCHD.ie©2016 Dr. ÍOS

Antibiotic interactions

Antibiotic Class Interacting Drug Comment
Macrolides e.g. Erythromycin, Clarithromycin Statins Risk of myopathy. Simvastatin contraindicated with clarithromycin and erythromycin. Where possible, hold pravastatin or atorvastatin whilst on macrolides, or consult product literature for statin dosing advice.
Warfarin* Risk of bleeding. Monitor INR closely.
NOACs* - Dabigatran,
Rivaroxaban, Apixaban, Edoxaban
Monitor, increased risk of bleeding.
Drugs that prolong QT interval** Consider risk vs. benefit for each individual patient.
  Colchicine Contraindicated with clarithromycin
Metronidazole Warfarin* Increases half-life of warfarin by 60% - Monitor INR closely.
Quinolones e.g. Ciprofloxacin, Levofloxacin, Moxifloxacin Warfarin* Risk of bleeding. Monitor INR closely.
Drugs that prolong QT interval** Consider risk vs. benefit for each individual patient. (Moxifloxacin – contraindicated)
Amiodarone Avoid due to increased risk of arrhythmias
Antacids / Iron / Calcium / Dairy products / phosphate binders Risk of reduced bioavailability and efficacy.
Separate the doses by 2 to 3 hours or more to avoid interaction.
Tetracyclines e.g. Doxycycline, Lymecyclin, Minocycline Antacids Risk of reduced bioavailability and efficacy.
Separate the doses by 2 to 3 hours or more to avoid interaction.
Iron
Calcium
Warfarin* Risk of bleeding - monitor INR closely.
Carbapenems  e.g. Meropenem Sodium Valproate Contraindicated - Potential for inadequate seizure control.
Linezolid Serotonergic Drugs*** Caution, risk of serotonin syndrome.
Trimethoprim
and Co-Trimoxazole
Warfarin* Risk of bleeding - monitor INR closely
Methotrexate Risk of severe bone marrow depression avoid is possible
Amiodarone Avoid due to increased risk of arrhythmias.
Systemic Fusidic Acid Statins Risk of myopathy. Avoid if possible or hold for duration of antibiotic treatment and for a further 7 days.
Rifampicin Consult product SPC for extensive list. Causes many drug interactions due to potent enzyme induction. May require dose adjustment or additional monitoring.
Azole Anti-fungals e.g. Ketaconazole, Fluconazole, Miconazole (incl. Daktarin oral gel) Statins Risk of myopathy. Recommended to hold the statin for duration of antibiotic treatment.
NOACs – Dabigatran,
Rivaroxaban, Apixaban, Edoxaban
Not recommended, increased risk of bleeding.
Warfarin Risk of bleeding. Monitor INR closely.
Drugs that prolong QT interval** Consider risk vs. benefit for each individual patient.

* Warfarin and NOACs: Penicillins and cephalosporins are preferred alternatives when patients are on anticoagulants. Documented reports of bleeding incidents are rare even though a theoretical risk exists. Monitor INR during warfarin treatment.

** Drugs that prolong QT interval: Imidazoles, tricyclic antidepressants, atypical antipsychotics, amiodarone & other anti-arrhythmics, some antidepressants (citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone, venlafaxine) alfuzosin, chlorpromazine & domperidone, galantamine, haloperidol, indapamide, lithium, methadone, quinine sulphate, tamoxifen, tizanidine, co-trimoxazole. For or a composite list of drugs that can prolong QT Interval visit www.crediblemeds.org.

Non-drug risk factors for ↑ QTc: Family history, electrolyte abnormalities (hypokalaemia, hypocalcaemia, hypomagnesaemia), cardiac ischaemia, cardiomyopathies, hypothyroidism and hypoglycaemia.

*** Serotonergic Drugs: Triptans (e.g. sumatriptan); antidepressants; antipsychotics; anticonvulsants; antiparkinsonian agents; analgesics (e.g., fentanyl, pethidine, tramadol); cough and cold medication containing dextromethorphan; herbal products (St. John's wort). This is not a complete list; please consult with product SPCs for further information.

OF NOTE: Combined Hormonal Contraception: Guidance from the UK Faculty of Sexual & Reproductive Healthcare no longer advises that extra precautions are required when using combined hormonal contraception (CHC) with antibiotics. (Unless those antibiotics are enzyme inducers e.g. rifampicin, rifabutin, isoniazid).

Alcohol & Metronidazole: A disulfiram-like reaction can occur between metronidazole and alcohol. The reaction is generally more unpleasant than serious. Warn all patients of the potential effects (flushing and tachycardia). A reaction can occur up to 72 hours after stopping metronidazole.

Guide©2016 Dr. ÍOS

NCHDs

NCHDs

NCHD.ie©2016 Dr. ÍOS

Intern Guide

Interns

NCHD.ie©2016 Dr. ÍOS

Welcome - Interns

Welcome to

Floating

Bricking it aren't you?

It is so very easy to sit here a few weeks from the end of intern year and tell you that it wasn't that bad, that you have nothing to worry about and that you will be grand. That old 30th June feeling has been replaced with that second Sunday in July feeling, and nothing will make it go away. Except of course the feeling you'll have when it hits 5pm on 11th July. You'll have done it then, one day down and only 364 minus holidays, weekends, bank holidays and sick days to go. That's like 250 or 270 tops!

You are able for this, you have read, studied, learned and practiced for five years and you know a lot more than you think you do. You know a lot less than you think you do too, but that you will pick up in a matter of weeks. Intern year may feel like an endpoint, but it is not. This is just an addendum to your studying, you will learn more this year than in the last two years of college - practical, useful stuff that just can't be read in a book. And that's what you're here for.

This guide is written by interns who have been around the block of CUH, and made it out the other side. It's written for interns about to start that journey for themselves. If you need to know a phone number, it's in here; if you're not quite sure where the radiology regs are hiding (and they are hiding), we'll tell you in here; if you do not know which blood test goes in which bottle, look in here and if you're starving and the canteen is closed and the microwave in the res is broken again, look up local numbers.

So take a deep breath and remind yourself that you are a capable, confident young doctor who will graciously take the advice of your senior colleagues be they nurses, doctors, healthcare assistants or porters. Whether it's patient management or which box you're supposed to leave your blood samples in, they do know better. But you must trust yourself above all other people.

So take a deep breath, close the EMed.ie and try to get some sleep on Sunday night. Because honestly, it's not that bad, you have nothing to worry about and you will in fact be grand. You did bring your pen right??

All the best!

Brendan, Catriona & Mwenya

Dr. Íomhar O' Sullivan

NCHD.ie©2016 Dr. ÍOS

Intern commandments

Intern commandments

  1. Thou shalt not leave day jobs and admissions for on-call colleagues.
  2. Thou shalt not forget thy busy colleagues on-call.
  3. Thou shalt hand over seriously ill patients.
  4. Thou shalt remember to eat, drink and take a break when on-call.
  5. Thou shalt keep thy cool.
  6. Thou shalt call for help.
  7. Thou shalt answer thy bleep.
  8. Thou shalt attend intern teaching.
  9. Thou shalt take thy holidays.
  10. Thou shalt have fun!
NCHD.ie©2016 Dr. ÍOS

Preps

Preps for procedures

If required, please place any IV line on the back of the hand (keep it out of the way should the cardiologist be using radial access).

Diazepam is usually only given to patients who are highly anxious and NOT charted routinely.

Angiography/Interventional

  1. Normal creatinine for procedures requiring IV contrast.
  2. If abnormal consider US/MR Angiography instead.
  3. Cessation / reversal of medications affecting bleeding /coagulation.
  4. Consent.
  5. IV Access.
  6. FBC, U&E.
  7. INR & APTT.
  8. Fasting 6hrs.

Bronchoscopy

  1. IV line.
  2. Coag.
  3. Consent.
  4. Risks: Bleeding, Infection, MI, Pneumothorax.

Cardioversion

  1. ECG directly prior to procedure to confirm still fibrillating.
  2. Coag: Confirm INR therapeutic.
  3. Consent.
  4. IV line.
  5. Consider accompanying patient to theatre as you may be allowed to do it.
  6. Risks: ECG changes, Arrhythmias, Myocardial necrosis, Transient ↓BP.

CT

  1. Ensure creatinine is normal prior to any scan requiring IV contrast.
  2. Thorax /Abdomen/ Pelvis / fasting 6 hrs.
  3. CT Colonography 1 & 2 above and full bowel preparation. Ask for CT Colon bowel prep protocol at reception.
  4. CT guided biopsies & drainages /- As for angio. / interventional prep.

Endoscopy

Your reg. will invariably ask for an INR (in case of need for biopsy) so try to have this result available before sending the patient down. Make sure you have also consented the patient (incl. biopsy).

Fluoroscopy / IVP

  1. Barium Swallow / Meal / Follow Through need Fasting 6 hrs.
  2. Barium Enema need Bowel preparation: ask at reception for barium enema bowel prep protocol.
  3. Venography need Normal creatinine.
  4. IVP need normal creatinine.

MRI

  1. For Patients requiring contrast, please include the patient’s most recent Creatinine level on the request form.
  2. IV access (Pink/Blue) will also be required for in-patients that are having contrast exams.
  3. Please ensure that the patient safety questionnaire is completed accurately and in full.
  4. Do not refer patients that have pacemakers, or are known to have metal in their eye. These are total contraindications. Please organise orbit x-rays or chest x-rays if you are unable to ascertain these key safety questions.
  5. Patients with artificial heart valves, aneurysm clips, stents, shunts, implanted devices or prosthetics need careful vetting before MRI can be performed. So ensure you provide the correct information to the MRI department. Get family members to assist if the patient has difficulty in communicating.

PET CT

  1. Fasting for an absolute minimum of 6 hours prior to scan.
  2. During 6 hour fasting period, PLAIN WATER ONLY is allowed. No sweets, chewing gum, or other little treats that could result in the scan being cancelled are allowed. Target blood sugar levels for scan are 4.1-8.3 mmol/L.
  3. For diabetic patients, please contact PET CT Department for additional instructions.
  4. In-patients require IV access prior to arriving in PET/CT (blue or pink).
  5. Avoid booking patients for other procedures on same day as PET/CT to allow radiation to decay.

Prep. for theatre

  1. ECG in male > 40 or female > 50 or if Hx of IHD.
  2. Bloods only if clinically indicated.
  3. Patients going for major surgery will need full work-up i.e. FBC, U&E, Coag, G&S/ G&C in major procedure.
  4. Some patients require CXR pre-op. If in doubt, ask your SHO.
  5. Consent.

Beware. Often difficulties surrounding patients on anticoagulants - it should be mentioned at time of booking whether they are on aspirin, Clopidogrel, Warfarin or on a NOAC. Usually Aspirin should not be a problem.

Ultrasound

  1. US Abdomen need fasting 6hrs.
  2. US Pelvis need full bladder.
  3. US guided biopsies & drainages need as for angio. or interventional prep.
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Referrals

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Coroner

Coroner

Role

The Coroners’ core function is to investigate sudden and unexplained deaths so that a death certificate can be issued. The Coroner Service not only provides closure for those bereaved suddenly but also performs a wider public service by identifying matters of public interest that can have life/death consequences.

Reporting of a Sudden Death

Those deaths which should be reported to a Coroner are listed in the Deaths Reportable section of the coroners.ie site.

In summary, these are deaths that are sudden, unexpected, violent or unnatural.

What happens when a death is reported?

When a death has been reported to the Coroner, they or their staff will contact the doctor of the deceased and establish if:

If these conditions are met, and there are no other matters needing investigation, the Coroner will allow the doctor to complete a Medical Certificate of the Cause of Death and the death will be registered with the Registrar of Deaths. No unnatural causes of death can be certified by a doctor. Based on the information available, the Coroner will decide:

What deaths are reported to the Coroner?

If in doubt as to whether or not a death is properly reportable, please consult with the Coroner who will advise accordingly. Please have a clear clinical (incl. PMHx) available before contacting the coroner. The fact that a death is reported to the Coroner does not mean that an autopsy will always be required.

Contact: (office) or Coroners mobile number via switch (The Coroner is available for consultation outside office hours, however except when the matter is urgent cases will normally be reported before 11pm or after 7am).

NCHD.ie©2016 Dr. ÍOS

Daffodil

Daffodil centre

The Daffodil Centre is an extension of the Irish Cancer Society’s ‘Cancer Information Service’. This free service offers confidential advice, information, and support to anyone worried about any aspect of cancer through a number of mediums. The Irish Cancer Society has been establishing Daffodil Centres where cancer care is delivered, as there is a body of international evidence showing that having access to the type of support that a Daffodil Centre provides can contribute positively to patients and their families throughout their cancer journey.

There are currently four Daffodil Centres based in the Munster region, these are located in Cork University Hospital, Bon Secours Hospital Cork, Waterford University Hospital, and University Hospital Limerick. Daffodil Centres provides free cancer information, support and advice. Last year the Cork Daffodil Centres received 5,978 contacts.

The CUH Daffodil Centre service runs from 9am-5pm Monday-Friday and is run by a specially trained cancer nurse and volunteers. No referral or appointment is necessary. Staff can be assured they are directing their patients to a trusted source of support and information, delivered by a professional and expert organisation.

Who can use the Daffodil Centres

Daffodil Centres are open to all, no referral or appointment is necessary: cancer patients (in-patients and out-patients), family members and the general public can come in and get information, including:

Contact details:

Tel: (021)4234536.

Email: daffodilcentrecuh@irishcancer.ie.

Visit: cancer.ie/how-we-can-help/daffodil-centres/university-hospital-cork

Cancer Nurseline Freephone: 1800 200 700.

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Administration

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Header

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Intern posts

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Common calls

Common calls

Documentation:

Whenever you treat a patient ("routine" contact or "on-call") “always write your impression of the patient and a plan”.

When you are on call always begin your note with the date, time, your rank (MIOC) and your name. All your notes during the day should contain the same information. It is also important to include the patient’s name and MRN at the top of your notes. Each page of medical notes should contain the MRN and name.

Every note should end with a signature and your MCRN.

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Fluids

Approach to fluids - adults
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Medications

Useful medications

The medication information was kindly updated by Fiona Ahern on 02/02/2015.



NCHD.ie©2016 Dr. ÍOS

Pain

Pain Mx Adults

Doses below are for adults >50kg. Consider mg/kg dose for adults < 50kg.

Refer problems with epidurals/local anaesthetic infusions/morphine via PCA to an anaesthetist.


The pain management advice was kindly prepared by Dr. Tim Keady (Intern in CUH 2014), Dr. Nick Barrett, Anaesthetic Reg., Dr. Dominic Hegarty, Pain Specialist, and Marih O'Leary, Pharmacist.

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IV Admin.

Useful IV Admin. guide

Antibiotic preparations.

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Nicotine replacement

Nicotine replacement therapy

Revised Fagerstrom Tolerance Scale


1. Assess Nicotine Dependence

0 1 2
How soon after you wake do you smoke? After 30 min Within 30 min  
Do you find it difficult to refrain from smoking where it is forbidden No Yes  
Which cigarette would you most be willing to give up? Any other First one in the morning  
Do you smoke more in the morning than the rest of the day? No Yes  
How many cigarettes do you smoke each day? Up to 15 16-25 >25
Do you smoke if you are so ill that you are in bed all day? No Yes  
What is the nicotine level of your usual brand of cigarettes Up to 0.9mg 1-1.2mg >1.3mg
Do you inhale the smoke from your cigarette? No Sometimes Always
Total      

2. Prescribe NRT

Score Cigarettes per day Recommended dose NRT
0-3
Low nicotine dependence
0-10 10mg if required
4-6
Moderate dependence
11-20 15mg

7+
High dependence

20+ 25mg

Points to note:

For High Dependency Smokers a 3 step down programme of NRT is recommended:

For Moderate to Low Dependency smokers a 2 step down programme is recommended:

3. Offer Support

From your local Smoking Cessation Services .

NCHD.ie©2016 Dr. ÍOS

NOACs

Useful NOACs

New Oral Anticoagulants.

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Header

Stroke prevention in NVAF

Prevention VTE post elective ortho surgery

Treatment of DVT or PE

Prevention of recurrent DVT & PE

Switching Warfarin to

Switching LMWH/UFH to

Switching to Warfarin

Switching from to LMWH/UFH

NCHD.ie©2016 Dr. ÍOS

Pain Mild

Pain Mild

Drug Dose Freq Route Note
Paracetamol 1g qds po/pr/iv In adults <50kg, IV dose is 15mg/kg max QDS. PO/PR route should be used unless contra-indicated.
Ibuprofen 400mg tds po Prescribe with PPI. See NSAID side-effects and contraindications. Less analgesia/anti-inflammatory action than diclofenac but side effects are less severe.
NCHD.ie©2016 Dr. ÍOS

Pain Moderate

Pain Moderate

Paracetamol + NSAID or Weak Opioid or both.

Drug Dose Freq Route Note
Diclofenac 75mg bd po

Max 150mg/24hrs. Prescribe with PPI.

See NSAID side-effects and contraindications.

PR route has no ⇓ in side effects and no ⇑ in analgesia.

Assess risk/benefit (e.g. cardiovascular risk factors) and use lowest dose for shortest duration.

Diclofenac now contraindicated in IHD, CVD, CCF, PVD.

Diclofenac 100mg 16hrly pr
Mefenamic
acid
500mg tds po

Prescribe with PPI.

See NSAID side-effects and contraindications.

Useful in both menstrual and inflammatory pain.

Tramadol 50–100mg qds po/im

See opioid side effects.

Avoid in epileptics and patients on medications which inhibit the re-uptake of serotonin (e.g. SSRIs, Linezolid).

In elderly can cause confusion, hallucination, N&V.

Good in neuropathic pain. Monitor INR (Tramadol can ⇑ INR).

NCHD.ie©2016 Dr. ÍOS

Pain Severe

Pain Severe

Drug Dose Freq Route Note
Oramorph 10mg 4hrly. po

Morphine solution

Morphine 5-10mg 4hrly im/sc

See opioid prescribing guide for side-effects and contraindications.

Morphine 5-10mg 4hrly iv Slow injection
OxyContin 5-20mg bd po

Prolonged release oxycodone.

OxyNorm 5-20mg 4hrly po

Oxycodone – good for breakthrough pain for patients on OxyContin or Targin - give 1/6 of total daily dose of opioid.

Pecfent 100mcg ii sprays
4hrly
IN

Fentanyl nasal spray – good for breakthrough pain.

Pecfent is cheaper than Instanyl and includes dose counter.

Actiq 200mcg i-ii
4hrly
po

Fentanyl lozenge – good for breakthrough pain and cancer pain.

One lozenge initially, repeated if necessary after 15 minutes.

No more than 2 lozenges for each pain episode.

If adequate pain relief not achieved with one dose unit for consecutive breakthrough pain episodes, increase the strength of the dose unit until adequate pain relief achieved with 4 lozenges or less daily.

Targin 5/2.5mg – 20/10mg po Prolonged release oxycodone with naloxone for prevention of opioid induced constipation. Restricted to initiation by a pain specialist only, where oxycodone + laxative was ineffective.
NCHD.ie©2016 Dr. ÍOS

Pain Compounds

Pain compounds adults

Useful Compound Medications

Drug Active
Ingredients
Dose/Route/Freq Note
Solpadol Paracetamol
Codeine
500mg/30mg ii po qds See opioid side-effects and contraindications. Caution against dual prescription of paracetamol.
Solpadeine Paracetamol
Codeine
Caffeine
500mg/8mg/30mg ii po qds See opioid side-effects and contraindications. Caution against dual prescription of paracetamol.
Cyclimorph-10 Morphine
Cyclizine
10mg/50mg i im tds Max 3 doses/24hrs. Not to be used in case of MI; Cyclizine may aggravate heart failure.

Antispasmodics

Drug Active Ingredients Dose/Route/Freq
Buscopan Hyoscine Butylbromide 20mg po qds
Colofac Mebeverine 135mg po tds
NCHD.ie©2016 Dr. ÍOS

Prescribe controlled meds

Prescribe controlled drugs

Legal requirements for Controlled Drug prescription (CD schedule 2 & 3)

NCHD.ie©2016 Dr. ÍOS

How to prescribe

Prescription writing policy for CUH

  1. Drug charts must include patient’s full name and hospital number and date of birth. Preferably attach an addressograph sticker.
  2. Drugs must be prescribed legibly and in capital print.
  3. Prescriptions must be signed by a registered medical practitioner & include the prescriber’s bleep number.
  4. Names of drugs must be in generic format except:
    1. Combination drugs e.g. FRUMIL.
    2. Preparations using slow or modified release formulations e.g. MST
    3. The following drugs because of reasons of bioequivalence: all lithium, theophylline & diltiazem products.
  5. Abbreviations e.g. NSA, GTN, ASA are not permitted.
  6. Corrections can only be made by re-writing the prescription; crossing out, tipp-ex etc. are not permitted.
  7. Discontinued drugs must be signed & dated by the prescriber.
  8. All drugs prescribed on separate charts, e.g. Insulin must be included on the prescription chart.
  9. Doses should follow the normal convention as follows; g for grams, mg for milligrams, micrograms & nanograms written in full. Avoid decimal points where possible, e.g. 250micrograms not 0.25mg.
  10. Drug sensitivities (allergies) should be entered in the allocated box.
  11. The same guidelines apply for drug prescriptions on HIPE forms & yellow prescriptions.
NCHD.ie©2016 Dr. ÍOS

Prescribe NSAIDs

NSAID Prescribing

Caution in:

Prescribe with PPI.

NCHD.ie©2016 Dr. ÍOS

Prescribe Opioids

Opioid prescribing for patients on chronic opioids

Clarify total daily regular dose + PRN given over last 24 hours and prescribe equivalent. (SC/IM/IV Morphine dose x2 = Equivalent oral dose of morphine.) If increased dose is needed, 25% increase is good starting point. Titrate dose to response/side effects.

Side effects.

Nausea, drowsiness are common, but tolerance develops in 5-7 days; respiratory depression; constipation; confusion; hallucinations; especially in elderly. Myoclonus is a sign of toxicity due to build up of metabolites.

Prescribe anti-emetic PRN and regular laxative. Lactulose 15mls BD with PRN Senna recommended (Lactulose can take 48 hours to take effect).

Reversal

For suspected respiratory depression, evaluate for RR<8 bpm, hypoxia, difficulty rousing. Naloxone: goal of therapy is to control the resp rate, not completely reverse opioid effect. Give 0.4mg IV q 2-3 min until resp. rate above 12/min. Effect lasts 15-90 mins. After initial reversal, give continuous infusion at hourly rate of 1/3rd of dose needed to reverse. See EMed.ie for further info.

NCHD.ie©2016 Dr. ÍOS

Heparin

Heparin

Dose adjustments based on APTT ratio / APTT (sec)
# APTT
Ratio
# APTT
(secs)
Heparin Infusion Rate (change) Recheck
APTT
(hours)
> 6.6 > 178 Stop infusion for 1 hour, then
↓ by 500 units/hr (↓ by 1ml/hr)
(and maintain this rate until next APTT)
4
5.1 – 6.6 137 – 178 ↓ by 500 units/hr (↓ by 1ml/hour)
(and maintain this rate until next APTT)
4
4.1 – 5.0 110 – 136 ↓ by 300 units/hr (↓ by 0.6ml/hour)
(and maintain this rate until next APTT)
4
3.1 – 4.0 84 – 109 ↓ by 100 units/hr (↓ by 0.2ml/hour)
(and maintain this rate until next APTT)
4
2.6 – 3.0 70 – 83 ↓ by 50 units/hr (↓ by 0.1ml/hour)
(and maintain this rate until next APTT)
4
1.5 – 2.5 40 – 69 No change if patient clinically stable 4
1.2 – 1.4 33 – 39 ↑ infusion by 200 units/hr (↑ by 0.4ml/hr)
(and maintain this rate until next APTT)
4
< 1.2 < 33 ↑ infusion by 400 units/hour (↑ by 0.8ml/hour)
(and maintain this rate until next APTT)
4

# Use APTT Ratio if available. If not, use APTT (secs) and adjust dose accordingly.

Please check EMed.ie for more details / print prescription chart.

NCHD.ie©2016 Dr. ÍOS

Insulin
sliding scale

Insulin Sliding scale

Insulin sliding scale CUH
Capillary Blood Glucose (mmol/L) Insulin (units/hr)
<4.5 Hold infusion
4.5-6.5 1
6.5-9 2
9-17 4
17-28 8
28 10

50ml syringe.

Dilute 50 units Actrapid to total of 50 mls normal saline (giving 1 unit/ml).

Dilute in saline (for hyperglycaemia) or 5% dextrose (for hyperkalaemia).

Start infusion depending on hourly GM readings as follows: Check level at 22:00 hours. If BM stable at 6-7 mmol, halve infusion rate overnight and check BM hourly.

BMs may be checked 2 hourly if stable.

IV fluids should be administered through a separate cannula.

Dextrose saline should be used if capillary blood glucose is less than 12mmol/l and normal saline should be used at higher glucose levels. The rate of fluid administration will be governed by the patient’s fluid requirements, state of hydration, etc.

Subcutaneous insulin can be recommenced when the patient is eating and drinking as normal.

N.B. This sliding scale is arbitrary. Insulin requirements vary from person to person and you may need to alter this accordingly.

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Procedures

Procedures

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Local information

Take Aways


Maps

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Feedback

Rate us please

Close Thank you for submitting your feedback.
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Calc

Calculators



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ABCD2

ABCD2 score


Stroke risk after TIA


ABCD2 =

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AG

Anion Gap


Anion gap =


Metab Acidosis
↑ AG Metab. Acidosis Normal AG Metab. Acidosis

MUDPILERS

  • Methanol
  • Uraemia
  • DKA/Alcoholic KA
  • Paraldehyde
  • Isoniazid
  • Lactic Acidosis
  • Etoh/Ethylene Glycol
  • Rhabdomyolysis
  • Salicylates

HARDUPS

  • Hyperalimentation
  • Acetazolamide
  • Renal Tubular Acidosis
  • Diarrhoea
  • Uretero-Pelvic Shunt
  • Post-Hypocapnia
  • Spironolactone
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Barthel

Barthel Index

Activities of Daily Living


Barthel index =

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CHADS2 score

Risk of Stroke in AF


CHADS2 score =


CHADS2
Score
Annual
Stroke
Risk %
Advice
0 2 No anticoagulation
1 3 ± anticoagulation
2 4 Oral
anticoagulation
recommended
3 3
4 9
5 13
6 18

More on EMed.ie

NCHD.ie©2016 Dr. ÍOS

eGFR

eGFR

eGFR is estimated GFR calculate using the abbreviated MDRD equation:

eGFR (ml/min/1.73m2) = 186 x (Creat / 88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black)


eGFR = 00 (ml/min/1.73m2) =

Normal GFR is approx. 100mls/min/1.73m2.

This formula is inaccurate in those with extremes in muscle mass (creatinine).

This formula is accurate in those with chronic renal disease but underestimated GFR in healthy patients.

The MDRD equation is not valid for children.

NCHD.ie©2016 Dr. ÍOS

Gentamicin once-daily dosing

Gentamicin once-daily dosing


This calculator computes the correct dose of gentamicin for a once-daily dosing regimen, in accordance with Cork University Hospital (CUH) antimicrobial prescribing guidelines (updated May 2016).

Renal impairment and obesity are taken into account when calculating the dose.

The once-daily gentamicin regimen should not be used for patients with endocarditis, meningitis, extensive burns, severe renal impairment, or patients on dialysis or haemofiltration.


  • (height required if
    patient is overweight)
  • Feet:Inches:

nchd.ie ©2016 Dr. R. McEvoy

HEART score

HEART score


For risk stratifying ED patients with chest pain


HEART score = :


Risk factors: DM, smoker, ↑BP, FHx of CAD, ↑Lipids

Score 1-3: 2.5% MACE over next 6/52 » Discharge home

Score 4-6: 20.3% MACE over next 6/52 » Refer cardiology

Score 7-10: 72.7% MACE over next 6 weeks » Admit cardiology

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ChadsVASC

ChadsVASC


CHA2DS2-VASc score =

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⇓Na+

Na+ deficit in hyponatraemia


Na+ requirement (mmol) =
total body water x (target Na+ - serum Na+ )

Rate of infusion (ml/hr) =
(Na+ requirement (mmol) x 1000) / (infused Na+ (mmol/L) x time (hours))


0.9% NaCl (154mmol/L) rate: ml/hr for hours.

The above formula does not include insensible water losses.


Total body water

Children
0.6 x weight
Women
0.5 x weight
Men
0.6 x weight
Elderly women
0.45 x weight
Elderly men
0.5 x weight

Ref: Adrogue, HJ, Madias, NE. Hyponatremia. NEJM 2000; 342(21):1581-1589.

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Olde

For the older ones


1 olde stone = 6.35026 kg

1 olde pound = 0.45359 kg

1 olde foot = 30.48 cm

1 olde inch = 2.54 cm


Weight: 000 kg


Height: 000 cm

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NIHSS

NIHSS


  • NIHSS=

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OSM

Osmolarity


Calculated Osmolarity = 2 Na + 2 K + Glucose + Urea ( all in mmol/L)

Osm: 0


Osmolar Gap = Serum Osm (lab) - Calculated Osm

Normal Gap 10 to 15 mOsm/kg water

Causes: ↑ Osmolar Gap

A) ↓serum water

B) Unmeasured Osm

For more please see EMed.ie

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PERC

PERC rule


PERC rules out PE if no criteria are present and pre-test probability is low. No need for further tests as <2% changce of PE.


Probability of PE <2%


NCHD.ie©2016 Dr. ÍOS

Vancomycin intravenous dosing

Vancomycin intravenous dosing


This calculator computes the correct doses of vancomycin for an intravenous dosing regimen, in accordance with Cork University Hospital (CUH) antimicrobial prescribing guidelines (updated May 2016).


  • (height required if
    patient is overweight)
  • Feet:Inches:


nchd.ie ©2016 Dr. R. McEvoy

Wells DVT

Wells score DVT


Validated Out-patient model for estimating pre-test probability of DVT.

Low probability : d-dimers will help exclude DVT.

High probability: do not do d-dimers but requires imaging

Score =

DVT "Likely" if Well's ≥2
DVT "Unlikely" if Wells ≤1


NCHD.ie©2016 Dr. ÍOS

Wells PE

Wells score PE


Pre-test probability of PE


  • Score =

    Wells Score >4 = PE likely. Consider imaging.

    Wells Score 0-4 = PE unlikely. Consider D-dimer to rule out PE.


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