Neuro/ Stroke + SBM 8 Flashcards
SBM 8 NEURO Units
Neurosurgery
Neurohospitalist - care team
Emergency NSGY
Cerebrovascular (stroke) - care team
Epilepsy monitoring
Trauma Verde
When working up patients … here are some tips about comparing inpt MAR and med list at home
- Look at the disease states they have and what medications they should be on
- Compare the MAR to med list - make sure all meds in MAR have an indication for the disease state…are they missing any meds for any disease state?
- Check Med list…see what they were getting at home and if any should be started or D/C based on their disease state…ex.. in stroke patients? make sure to D/C any stroke causing medications like tadalifil.
Patient is on DAPT - but need biospy, when to stop Plavix and when to stop ASA?
Stop plavix for 5 days , stop ASA for 3 days - this is dependent on procedure!
Importance of checking Diet?
Very important! For any patient group! because if NPO you dont wanna give meds - depeneding…this is of high importance for Stroke patient because stoke can efeect speech and swallowing! - DYSPHAGIA - difficulty swallowing! thus the patient may have a NPO diet put on them first then the nurse will go and do a bedside speech study (can be found in form browser) - if they FAIL? then true NPO and make sure they cannot get meds PO! but if they pass you can do PO meds - may need to check stutus with team first
When completing D/C for Stroke and HF patient
The residents / MD should be doing this… and we just check them. but basically we need to look at their med list and compare it to MAR and our plans of what we have for them is appropriate and then make sure to type out the instruction in lay person term for example – Aspirin “For heart health/ stroke prevention - Next dose due 2/26/25 at 9:00 AM” and for metformin “For blood sugar (don’t put high) - Next dose due 2/26/25 at 9:00 AM” — then after you’re done you can notify case manager if they are going to a facility! —- and IF THEY ARE GOING HOME PLEASE MAKE SURE ITS A RX WITH REFILLS (pill bottle - not scroll)
Vitamin D supplement caveats
High dose once a week - typically for if vitamin D levels are below ~12, the once a day dosing can be fore + 13
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For patients with vitamin D levels indicating insufficiency or deficiency, the need for once-a-day dosing is typically considered when serum 25-hydroxyvitamin D [25(OH)D] levels are below 20 ng/mL.
Drugs that can cause stroke
-nib, oral contraceptives, tamoxifin,
1. Erythropoietin: High level of evidence for association with ischemic stroke.[1]
2. Combined contraceptives: High level of evidence for association with ischemic stroke.[1]
3. Oral estrogen replacement therapy: High level of evidence for association with ischemic stroke.[1]
4. Bevacizumab: High level of evidence for association with ischemic stroke.[1]
5. Tamoxifen: High level of evidence for association with ischemic stroke.[1]
6. Antipsychotics: High level of evidence for association with ischemic stroke.[1]
7. Ponatinib: Moderate level of evidence for association with ischemic stroke.[1]
8. Nilotinib: Moderate level of evidence for association with ischemic stroke.[1]
9. Darunavir: Moderate level of evidence for association with ischemic stroke.[1]
10. Gonadotropin-releasing hormone agonists: Moderate level of evidence for association with ischemic stroke.[1]
11. Short-acting antihypertensives (e.g., nifedipine, labetalol, captopril): Associated with increased risk of ischemic stroke.[2]
12. Mood stabilizers (e.g., carbamazepine, valproic acid): Associated with increased risk of stroke in patients with bipolar disorder.[3]
13. Sympathomimetics (e.g., phenylpropanolamine, pseudoephedrine): Associated with stroke, particularly hemorrhagic stroke.[4]
14. Drugs of abuse (e.g., cocaine, amphetamines, heroin, morphine, cannabis, synthetic cannabinoids): Associated with both ischemic and hemorrhagic stroke.[5-6]
Length of DAPT
- PCI
- CABC (coronary artery bypass graft)
- PCI: 6 months
- CABC: 12 months
Repeat blood culture for gram + vs gram -?
Gram-positive bacteria, particularly Staphylococcus aureus, are associated with a higher risk of persistent bacteremia. Persistent bacteremia with gram-positive organisms can indicate serious underlying issues such as endocarditis or other deep-seated infections, which require prolonged and targeted therapy. Therefore, repeat blood cultures are recommended to ensure that the bacteremia has cleared and to guide further management.[1-2]
Gram-negative bacteria, on the other hand, typically cause transient bacteremia that resolves rapidly with appropriate antibiotic therapy and source control. Studies have shown that follow-up blood cultures (FUBC) for gram-negative bacteremia add little value in the management of these infections, as persistent bacteremia is uncommon unless there is inadequate source control or inappropriate antibiotic therapy. Consequently, routine repeat blood cultures are generally not necessary for gram-negative bacteremia unless there are specific clinical indications such as ongoing signs of sepsis or failure to respond to treatment.[2]
In summary, repeat blood cultures are recommended for gram-positive bacteremia due to the higher risk of persistent infection and its clinical implications, whereas repeat cultures are generally not needed for gram-negative bacteremia due to its typically transient nature and rapid resolution with appropriate treatment.
If patient recently took DOAC with in ______ then do a APTT level prior to heparin
When transitioning a patient from a direct oral anticoagulant (DOAC) to heparin, it is important to measure the activated partial thromboplastin time (aPTT) to ensure that the anticoagulant effect of the DOAC has sufficiently diminished. This is necessary to avoid the risk of excessive anticoagulation and bleeding when initiating heparin therapy.
The timing for measuring aPTT depends on the pharmacokinetics of the specific DOAC taken by the patient. For example, the half-life of DOACs such as apixaban, rivaroxaban, and edoxaban is typically around 9-17 hours, depending on renal function and other patient-specific factors.[1-2] Therefore, it is generally recommended to wait at least 24 hours after the last dose of a DOAC before measuring aPTT to ensure that the drug’s effect has sufficiently waned.[1-2]
Measuring the aPTT level in this context is necessary because DOACs can prolong aPTT, and initiating heparin without accounting for the residual anticoagulant effect of the DOAC can lead to an inaccurate assessment of heparin’s anticoagulant effect. This can result in inappropriate dosing adjustments and increased risk of bleeding complications.[1-2]
General bug/ drug for endocarditis
More Glucomander caveats - when should you switch patient from sliding scale to glucommander?
If the patient’s glucose is not controlled and there are crazy flucuations - 300-60… can do glucommader instead for better control
Medications you should not used after Stroke
Celecoxib (Celebrex) should be avoided within 6 months of a stroke due to its association with an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke. This risk is particularly significant in patients with a history of cardiovascular disease or risk factors for cardiovascular disease.[1] The FDA has issued warnings about the cardiovascular risks associated with chronic use of celecoxib, emphasizing that patients with known cardiovascular disease or risk factors may be at greater risk.[1]
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Other medications that should be avoided after a stroke include:
1. Nonsteroidal anti-inflammatory drugs (NSAIDs): All NSAIDs, including both COX-2 selective and non-selective NSAIDs, are associated with an increased risk of cardiovascular events and should be used with caution in patients with a history of stroke.[2-3]
2. Selective serotonin reuptake inhibitors (SSRIs): These medications have been associated with an increased risk of bleeding, including intracerebral hemorrhage, and should be used cautiously in patients with a history of stroke.[2]
3. Antipsychotics: These medications have been associated with an increased risk of ischemic stroke and should be used with caution in patients with a history of stroke.[4]
4. Hormone replacement therapy (HRT): Oral estrogen replacement therapy has been associated with an increased risk of ischemic stroke and should be avoided in patients with a history of stroke.[4]
How many notes MPTL to do for each AC situations
- DOAC
- Warfarin
- Heparin drip (gtt)
- Heparin/ enox ppx
- DOAC: every 3-5 days if stable
- Warfarin: get INR daily (unless been stable for so long) + daily
- Heparin drip (gtt) - daily, get daily AntiXa level
- Heparin/ enox ppx - no notes
DVT PPX with heparin and enox for BMI greater than 40 ppl
- enox: 0.5mg/kg daily
- heparin: 7500 units Q 8hrs
When adding clinical notes (not MPTL) for vanco and animoglycoside
.adultvanco
.txp_admission - for transplant
Thyroid and it’s imporantance with stoke?
In summary, both low and high thyroid levels can increase the risk of stroke. Hyperthyroidism primarily increases the risk through atrial fibrillation and a hypercoagulable state, while hypothyroidism contributes to stroke risk through atherosclerosis and other cardiovascular risk factors.
Alteplase vs Tenecteplace (we use TNK now!) administration
Alteplase is administered as an intravenous infusion. The standard dosing regimen involves a bolus of 0.9 mg/kg (maximum dose of 90 mg), with 10% of the dose given as an initial bolus over 1 minute, followed by the remaining 90% infused over 60 minutes.[1-2] This requires continuous monitoring and the use of infusion pumps, which can be logistically challenging, especially in settings requiring rapid treatment or interhospital transfers.
Tenecteplase, on the other hand, is administered as a single intravenous bolus. The typical dose for stroke treatment is 0.25 mg/kg (maximum dose of 25 mg) given over 5-10 seconds.[3-5] This single bolus administration simplifies the process, reduces the need for infusion pumps, and can potentially decrease door-to-needle times, making it particularly advantageous in emergency settings and during patient transfers
digoxin..when do we see the effects of it on heart rate and when should we get a level
In summary, the effects of digoxin on heart rate are seen within 0.5 to 2 hours for oral formulations and within 5 to 30 minutes for intravenous administration. Digoxin levels should be checked at least 6 hours after the last dose to ensure accurate assessment.
The inclusion and exclusion criteria for using alteplase and tenecteplase in the treatment of acute ischemic stroke are as follows:
Inclusion Criteria:
1. Time Window: Patients must be able to receive treatment within 4.5 hours of symptom onset.[1-4]
2. Neurological Deficit: Patients must have a measurable neurological deficit, typically with a National Institutes of Health Stroke Scale (NIHSS) score of 5-25.[1-2]
3. Functional Status: Patients should have a modified Rankin Scale (mRS) score of 0-1 before the stroke, indicating no significant disability.[1-2]
4. Imaging: Non-contrast CT or MRI must exclude intracranial hemorrhage and show no extensive early ischemic changes.[5]
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Exclusion Criteria:
1. Hemorrhage: Presence of acute intracranial hemorrhage on imaging.[5]
2. Recent Stroke or Head Trauma: History of ischemic stroke or severe head trauma within the past 3 months.[5]
3. Coagulopathy: Platelet count less than 100,000/mm³, INR >1.7, aPTT >40 seconds, or PT >15 seconds.[5]
4. Recent Surgery: Recent intracranial or intraspinal surgery within the past 3 months.[5]
5. Severe Hypertension: Blood pressure >185/110 mm Hg that cannot be safely lowered. … if not getting TNK then BP goal is 130/90
6. Active Bleeding: Active internal bleeding or conditions that increase the risk of bleeding, such as recent gastrointestinal bleeding.[5]
7. Anticoagulant Use: Recent use of direct thrombin inhibitors or factor Xa inhibitors without normal coagulation tests.[5]
TTE or TEE to check for endocarditis?
TTE first because it’s less invasive…however, if you still have sus for endocarditis then can do TEE to rule it out!
Note to nurse staff when drawing vanco for CI - time study!
It is correct to instruct the nursing staff to draw a vancomycin level as a “clean stick” for continuous infusion of vancomycin. This practice is important to ensure the accuracy of the vancomycin level measurement. Drawing the sample from a site that is not used for the vancomycin infusion helps to avoid contamination and falsely elevated levels, which can occur if the sample is drawn from the same line through which the drug is being administered.
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The American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Disease Pharmacists recommend that therapeutic drug monitoring (TDM) for vancomycin should be performed accurately to guide dosing and avoid toxicity. This includes ensuring proper sampling techniques, such as using a clean stick, to obtain reliable serum concentrations.[1]
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In summary, drawing a vancomycin level as a “clean stick” is essential for accurate therapeutic drug monitoring, especially during continuous infusion, to avoid contamination and ensure appropriate dosing adjustments.
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please draw as clean stick in opposite arm of infusion
General stuff - when verifying stuff that is multiple times a day - a weird situation you might see with multiple gabapentin ordered… Lets say they want TID but the night dose is more/different
It’s easier to change it to BID (change time to AM and noon) and then a seperate dose that’s Q night.
General stuff - a weird situation - melatonin
“Q bedtime” = will autopopulate to 21:00 (9PM) ….but if they want it at a different time like 18:00 (6PM) you can do that - just change time to “18:00” instead of Q night and then just do “Q 24 hrs” that will adjust the time of future melatoin dose to 18:00
DDI of Plavix
CYP2C19 Inhibitors: Drugs such as omeprazole and esomeprazole significantly reduce the antiplatelet activity of clopidogrel by inhibiting its metabolism to the active metabolite (so opt for pantoprazole)
Which statins need to be taken at night ?
Statin medications with relatively short half-lives are recommended to be taken at night to maximize their lipid-lowering efficacy. This is because cholesterol synthesis in the liver is higher during the night. The statins that should be taken in the evening include:
* Simvastatin
* Lovastatin
* Pravastatin
* Fluvastatin
