BLS Mastery: How to Save a Life When Someone Collapses

Imagine someone collapsing right in front of you. Would you know what to do in those first critical moments?

Responding to a patient who has collapsed and in need of BLS

Basic Life Support (BLS) is a set of simple, but lifesaving skills designed to keep oxygen moving to the brain and vital organs when breathing or circulation stops. The goal is not only survival, but survival with the best possible neurological outcome until advanced medical care arrives.

Recognizing the Emergency

Medical emergencies can happen anywhere—at the grocery store, in church, on a sidewalk, or while hiking.


The goal is simple: keep oxygen moving into the body and keep blood circulating to the brain and other vital organs.


The first step is to check for responsiveness. Is the person conscious or unconscious?

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How to Check for Consciousness

You check for consciousness by tapping the patient with good pressure and asking:

Are you okay??!


A responsive person may not always be fully alert. Responses can include:

  • awake and able to answer questions
  • unable to speak but able to respond with purposeful movements, nodding, or blinking
  • it is not uncommon for patients to be conscious and confused


Ideally someone else is nearby to contact advanced medical professionals (911) and find an Automated External defibrillator (AED) if available. Your goal is to increase the chance of survival by supporting breathing, circulation and/or defibrillation until they get there.


If the person is conscious, that’s encouraging news. A conscious person is breathing and has enough circulation to maintain brain function. Let us consider the unconscious patient.

The Unconscious Patient

Scenario 1:

In the best-case scenario, your patient is unconscious BUT they have a pulse AND they are breathing normally.

This would include situations like fainting, concussions, symptomatic severe hypoglycemia, serious trauma and severe intoxication.

All of these are also serious medical emergencies, but it is obviously always better when your patient has a pulse and is able to breathe.

In this scenario the appropriate response will vary based on the specific cause. Monitor the patient until emergency services arrive.

Scenario 2:

The second-best scenario is where your patient is unconscious AND has a pulse BUT is not breathing normally or not breathing at all.

Depicting the heart and lung condition in a patient who is unconscious, has a pulse but is not breathing or not breathing normally.

A pulse means the heart is still pumping blood, but without breathing, oxygen levels will
quickly fall.

This would include situations like drowning where water in the lungs prevents normal breathing, choking, severe trauma to the chest and respiratory depression from narcotic overdose.

An unconscious person with a pulse but not able to breathe is in respiratory arrest.

Without intervention, respiratory arrest can progress to cardiac arrest.

In respiratory arrest give 1 breath every 6 seconds and check for a pulse about every 2 minutes until advanced medical help arrives.

Scenario 3:

The most critical scenario is a patient with NO pulse. Without a pulse your heart is not pumping blood.

Depicting the heart and lung condition in a patient who is unconscious, has no pulse and is not breathing or not breathing normally. Cardiac arrest.

Within seconds blood flow to the brain drops which will automatically result in a loss of consciousness.

The brain also controls the ability to breathe, and loss of respiratory function soon follows.

No pulse = no circulation + no consciousness + no breathing

A person with no pulse is in cardiac arrest.

In cardiac arrest we start CPR.

CPR

Start CPR immediately with compressions. Push hard and push fast. High-quality compressions will provide 100 –120 compressions per minute with a depth of atleast 2 inches for adults.

Common Pitfalls of CPR:

1. Not allowing the chest to completely recoil after each compression:

Allowing the chest to fully recoil between compressions lets the heart refill with blood before the next compression. This will result in more blood being pumped to vital organs with the next compression.

Image showing the effect of incomplete recoil of chest during compressions.

2. Over- ventilating:

Breaths during CPR should be given over 1 second. Just enough to see the chest rise. Blowing in too much air increases the pressure within the chest which decreases blood flow to the heart and subsequently to vital organs with the next compression.

3. Excessive interruptions

During CPR any interruption greater than 10 seconds is considered excessive.

Compression is the surrogate pulse for patients in cardiac arrest; it is the only source of blood flow to the brain and vital organs.

When compressions are paused blood flow/oxygenation to vital organs stops almost immediately.

Brain tissue is extremely sensitive to oxygen deprivation and will begin to deteriorate in about 5 minutes.

The 10 second rule applies for all interventions during CPR including checking for a pulse. If you cannot confirm a pulse within 10 seconds, start CPR.

Defibrillation/AED

If an AED is available turn it on and follow the audio and visual instructions on screen to
correctly attach the pads. The device analyzes the heart’s rhythm and tells you whether a shock is needed. Follow each shock immediately with CPR, beginning with compressions.

When attaching the defibrillator the 10 second rule still applies.

Conclusion

Basic life support can save lives with no advanced equipment. Stay calm, check for breathing and pulse, provide the support needed: breaths, compressions and/or defibrillation.

What to test how well you can apply this information in real clinical scenarios? Take the BLS quiz!

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Albumin: What Concentration to Use and How to Administer

Albumin administration is complicated because of its different concentrations and indications. By the end of this unit, you will be equipped to answer a common clinical dilemma: which concentration to use and how fast to give it.

What is Albumin & How it Works

We have 34-54 grams of albumin per liter of blood in our bodies; it is the most abundant plasma protein (~60%). Albumin is made primarily by the liver.

Its main purpose is to maintain the oncotic pressure of plasma. Oncotic pressure sustains the circulating blood volume; it maintains blood pressure, cardiac output and perfusion throughout the body.

Illustration showing the liver producing albumin and its role in maintaining oncotic pressure in blood vessels.

Albumin is too large to pass through the blood vessels; it remains in the intravascular system. This creates a higher solute concentration within the blood vessels which attracts water from extravascular spaces into circulation.

Albumin also plays a significant is role in drug, hormone and enzyme transport around the body.

The commercial preparation of albumin is a simply an aqueous solution of human albumin. We derive albumin from human donors. The donations are then fractionized and pasteurized to produce a sterile product.

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Clinical Indications for Albumin

We use albumin when there is some form of blood volume imbalance that we must restore. Whether from net loss or relative loss of circulating blood volume (explained below) albumin can temporarily compensate and maintain circulatory blood flow. This is why we refer to albumin as a “plasma volume expander”.

FDA approved indications include:

  • hypovolemia including hypovolemic shock and ovarian hyperstimulation syndrome
  • ascites including large volume paracentesis, spontaneous bacterial peritonitis, pancreatitis
  • severe burns

Albumin Formulations

25% Albumin:

This formulation contains 25g of albumin per 100 ml of solution.

Infographic explaining 25% albumin formulation, indicating 100ml administration results in 500ml plasma expansion.

25% albumin has approximately five times the oncotic pressure of plasma. That means it will increase the gradient for movement of interstitial fluid into the intravascular 5-fold. When we administer 100ml of 25% albumin we effectively administer 500ml of volume expansion.

25% albumin is therefore useful when there is a relative hypovolemia; the volume is present in other extracellular or interstitial compartments.

The efficacy of 25% albumin is fully dependent on the availability of interstitial fluid to flow into the blood vessels.

If nothing is available to pull from (like cases of severe dehydration), 25% albumin will be ineffective.

This higher concentration of albumin is therefore useful in conditions like fluid overload in decompensated heart failure, ascites, severe burns, extensive cellulitis, pancreatitis and septic shock/inflammatory vasodilation.

5% Albumin:

This formulation contains 5g of albumin per 100ml of solution.

Text graphic explaining that 100ml of 5% albumin equals 100ml plasma expansion, on a light blue circular background with a logo and website URL.

5% albumin is oncotically equivalent to that of plasma. This means that it will not increase the gradient for transport of fluid from the extravascular to the intravascular space. It simply stays within the blood vessels. When we administer 100ml of 5% albumin we effectively administer 100ml of volume expansion.

5% albumin is therefore useful when there is a net hypovolemia; there is an overall loss of volume in the body as a whole.

This is any occurrence of hypovolemia not related fluid shift.

Some examples are dehydration from excessive diuresis, severe diarrhea and vomiting, blood loss from major surgery or trauma.

Which to Use: 25% or 5%

Whenever you need to make the decision about which concentration of albumin is needed ask yourself:

Does my patient have a net hypovolemia or relative hypovolemia?

For net hypovolemia: use 5% albumin

For relative hypovolemia: use 25% albumin

How Fast to Administer Albumin

This is a very common question mainly because the rate of administration must consider the patient’s clinical status.

You can run albumin of either concentration relatively quickly (over 30 minutes) if your patient is clinically unstable due to hypovolemia. Our only limit to the rate of administration in this scenario is the capacity of the administration device. In addition, you can repeat the dose if there is an inadequate response in 15 to 30 minutes.

If your patient experiences adverse effects during the infusion, slow the rate. Adverse effects can include rigors and shortness of breath. With that said, albumin infusions are very well tolerated.

The rate of administration is more of a concern with lower acuity patients. We must consider the patient’s volume when selecting a rate of administration. We do not want to tip the scales into hypervolemia or rapidly increases in plasma volume because that can overload the body’s circulatory system. This is known as cardiovascular overload.

Signs of cardiovascular overload include headache and shortness of breath expanding to jugular venous distention and pulmonary edema. Stop the infusion, reassess the patient’s volume status and the continued need for albumin administration.

Bottom line: if your patient is hemodynamically unstable administer albumin quickly. If not administer over 2 hours increasing the rate of administration if desired and if patient demonstrates tolerability.

Test your knowledge with this free albumin quiz! You’ll have the chance to dive into questions that will not only assess your understanding of albumin’s vital roles and functions in the body but also enhance your learning experience. This quiz is a fantastic opportunity to deepen your insight so take a moment to challenge yourself and discover just how much you already know!

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

How to Analyze Antimicrobial Culture & Sensitivity Reports

It sounds simple, you look at the antimicrobial culture and sensitivity report and if it is susceptible, you can use it! If you’ve been in practice for any amount of time you know that is both true and false. You must possess a core understanding to correctly interpret and apply antimicrobial C&S reports to patient care.

In this unit we will look beyond the reported susceptible (S) or resistant (R) values reported. The goal is to show you how to look at your available options of susceptibility and make the best clinical decision for your patient.

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Antibiotic Stewardship

The goal with antimicrobial C&S reports is to analyze the results in such a way that you select the most narrow and specific coverage while considering costs, site of infection, drug interactions and disease state interactions.

A “susceptible” results means that there is a high likelihood of therapeutic success with appropriate dosing of that antibiotic. We will start with how the reported antibiotics are chosen.

Selection of Antibiotics Reported on Antimicrobial C&S

Have you ever wondered why some drugs are left off the susceptibility report even though they are likely susceptible?

Each lab will have a predefined list of antibiotics that they will test against a specific pathogen. However, not all the antibiotics tested will be provided on the antimicrobial C&S report. We refer to this as selective antibiotic reporting or cascade reporting.

Of all the antibiotics that are tested in the lab, what is eventually reported is filtered based on the degree of susceptibility, site of infection and ideally formulary.

1. Susceptibility

Diagram illustrating selective antibiotic reporting from antimicrobial culture and sensitivity, showing initial release antibiotics for MSSA and potential subsequent releases.

If a pathogen is highly susceptible the lab will only report narrow spectrum antibiotics.

If resistance is detected, lab will release additional, more broad-spectrum antibiotics.

For instance, do not report meropenem for highly susceptible MSSA. Do not report a 3rd generation cephalosporin if there is susceptibility to 1st and 2nd generation cephalosporins.

These policies will vary by institution. Some might restrict the reporting of linezolid for vancomycin susceptible MRSA, reserving its use for VRE. While some might argue that knowing the susceptibility is valuable for switching to oral treatment which facilitates quicker discharge.

2. Site of Infection

If a patient has a sample from the lungs that is susceptible to daptomycin in vitro (in lab) that should not be reported because daptomycin cannot penetrate the lungs and would therefore be ineffective for treating pneumonia.

In the United States, we use fosfomycin only for treating urinary tract infections.

If a bug shows susceptibility in a sample from any other site other than urinary, those results should be suppressed.

3. Formulary

To further complicate things, your best option may not be one of the drugs tested or reported. Ideally your facility will test only against drugs on your formulary.

If you notice that this not true for the antimicrobial C&S results at your facility, perhaps this is an opportunity to work with your microbiology department to optimize reporting. Narrowing down what is reported is an important first step in antibiotic stewardship. It is referred to as diagnostic stewardship.

Organization like the CLSI (Clinical and Laboratory Standards Institute) and EUCAST (European Society of Clinical Microbiology and Infectious Diseases) and the FDA (US Food and Drug Administration) have a wealth of resources to guide policies and procedures for antimicrobial testing and reporting.

Selection from Antimicrobial C&S

1. Choose the Narrowest Spectrum of Coverage

A simple way to visual the spectrum of antibiotic classes is to fit them into concentric circles with the narrowest option at the center. This will make is easier to choose the most appropriate options from the various antibiotics listed on the antimicrobial C&S report.

A concentric circle diagram illustrating various classes of antibiotics, showing narrow spectrum options like amoxicillin at the center and broader spectrum options like meropenem on the outer circles.

Of all the antibiotics reported as susceptible, chose the option that is closest to the center of the circles.

2. Your Best Choice May Not be Reported

Keep in mind that your best option may not be listed on the report. A good example is amoxicillin. Oral amoxicillin is still a very good, cost-effective option for penicillin susceptible staph infections. Ampicillin and nafcillin are other viable options that must be extrapolated from the report of penicillin susceptibility.

3. Use Gram Stain & PCR Testing

PCR testing uses the detection of genetic material specific to certain strains of bacteria. These will result faster (often within 24 hours) than the finalized antimicrobial C&S.

For instance, the detection of mecA/C suggests the presence of methicillin resistance, and you likely have MRSA.

Diagram illustrating the relationship between gram stain results and PCR testing for identifying methicillin-resistant Staphylococcus aureus (MRSA), featuring images of gram-positive cocci and genetic markers.

The presence of vanA/B suggest the presence of vancomycin resistance; you likely have VRE.

The presence of NDM suggests the presence of carbapenem resistance.

4. IV to PO Conversions

Use your C&S results to transition to oral antibiotics that are able to penetrate the site of infection. There are numerous benefits associated with PO conversions: cost savings, length of stays reductions and less risk of infection to name a few.

Common Pitfalls of Interpretation of Antimicrobial C&S

1. Consider Time of Draw

A common mistake I’ve seen in my 12+ year career is escalation to more aggressive antibiotics if an initial culture shows sensitivity to one of the empiric antibiotics. Whether out of haste or misunderstanding, this is interpreted as “a positive culture despite treatment with a susceptible agent” instead of assurance that the patient is being appropriately treated.

This may seem silly to some, but it is a misconception that does occur. So always look at the timing of the culture. Was it ideally drawn prior to initiation of therapy or was it a culture drawn after antibiotics were initiated for some time.

2. Consider Location of Infection

As discussed above, ideally your lab will suppress antibiotics that do not have reliable penetration to a specific site of infection. If they do not, you need to remember to apply your own filters.

3. The Role of Antibiograms

Antibiograms are valuable for helping you select empiric antibiotics before you know susceptibilities. Once you have C&S results, antibiograms should not guide your decisions.

Interpretation of culture and sensitivity results can be daunting, making it the prefect opportunity for you to add value to your team and deeply impact patient care.

You’ve learned how to look beyond the simple “Susceptible (S)” or “Resistant (R)” results and apply antimicrobial stewardship principles to real-world decision-making. Now it’s time to put your knowledge to the test.

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.
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How to Treat Neonatal Hypoglycemia

Our brains, especially that of a newborn, is dependent on glucose as the primary source of energy. Like most of their other bodily functions, glucose regulation is immature at birth. High glucose demand from rapid growth and high metabolic rates make newborns highly susceptible to neonatal hypoglycemia.

Low birthweight babies, preterm babies and babies born to moms with diabetes are at an increased risk for hypoglycemia. This is especially true during the transitional phase from womb to world.

We must treat prolonged or recurrent episodes of hypoglycemia immediately in neonates.

Our biggest concern is brain injury.

Specifically, edema and atrophy that can lead to permanent neurological damage which can manifest as cerebral palsy, epilepsy, deafness and blindness.

Here’s what you need to know about what drugs are needed, how to give them and 3 pitfalls to avoid.

Identifying Neonatal Hypoglycemia

We define neonatal hypoglycemia as a blood glucose of less than 40mg/dL. Hypoglycemia is always difficult recognize by symptoms. Nonspecific presentation in neonates ranges from poor feeding, tremors, twitching to seizures and coma.

We must also make the distinction between persistent hypoglycemia and normal fluctuations in blood glucose as the baby transitions out of the womb and establishes glucoregulaltion independent of mom.

Most newborn protocols will screen for hypoglycemia every 1-2 hours, increasing or decreasing surveillance frequency based on the presence or absence of signs and symptoms of hypoglycemia.

The treatment goal is to raise plasma glucose concentrations to 50-200mg/dL.

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How to Treat Neonatal Hypoglycemia

Dextrose administration is the foundation for correcting hypoglycemia in neonates. We will administer glucose via one of 2 routes depending on the severity and available route of administration.

1. Dextrose Gel

40% dextrose gel is indicated in mild cases of asymptomatic hypoglycemia. This is a baby who is able to feed, clinically stable and not is any distress.

How to Dose

We commonly refer to glucose gel as sweet cheeks.

Massage the gel into the buccal mucosa (the lining of the gums).

Prior to applying to the cheeks, dry the mouth with gauze and follow application of the gel with feeding (breast/bottle).

It is dosed at 0.2g/kg/dose or 0.5ml/kg/dose (see calculation below). Doses can be repeated up to 6 times in 48 hours.

A calculation guide for administering 40% dextrose gel to neonates, including dosage and conversions based on a child's weight.

2. Parenteral Dextrose

We use intravenous dextrose in babies who are:

  • Asymptomatic with mild hypoglycemia but unable to receive oral treatment due to inability to feed or clinical instability like respiratory distress.
  • Asymptomatic with severe hypoglycemia (plasma glucose <20mg/dL)
  • Symptomatic
How to Dose

D10% (a 10% dextrose solution) to commonly used in neonates with hypoglycemia.

We give a bolus dose to babies who are symptomatic. The recommended dose is 0.2 grams/kg (note the similarity in dosing glucose gel: both are 0.2g/kg). You must be particularly careful with the units used in calculations for pediatric patients Because a 10% solution is 10g of dextrose per 100ml this equates to a 2ml/kg rate which is how it is commonly ordered. Administered the bolus over 1-2 minutes.

Calculation of dextrose dosage for neonates, highlighting the bolus formula and solution concentration on a background of mathematical symbols.

A continuous infusion using either 5% or 10% dextrose may follow at a rate of 5-8 mg/kg/minute of dextrose titrated to achieve target glucose levels of 50-200 mg/dL.

Repeat blood glucose concentrations after 20-30 minutes in symptomatic neonates. In asymptomatic patients it can repeated in an hour.

Discontinued intravenous dextrose when plasma glucose levels have been stabile for atleast 24 hours.

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Pitfalls to Avoid

1. Abrupt discontinuation of intravenous dextrose

Administration of intravenous dextrose induces a corresponding increase in insulin release from the pancreas. The body clears endogenous insulin from plasma in 4-6 minutes. When we abruptly discontinue IV dextrose the high ratio of insulin to glucose creates the potential for rebound hypoglycemia.

I explain the mechanism of rebound hypoglycemia in this video on TPN administration.

Illustration depicting the insulin response when dextrose infusion is abruptly stopped, showing a dextrose bag, a pancreas, a baby, and an arrow indicating the risk of hypoglycemia.

Reduce the rate of the dextrose infusion by 1-2mg/kg/min every 4-8 hours to prevent rebound neonatal hypoglycemia.

2. Concentration Confusion

We can safely administer dextrose 5%, 10% and 12% dextrose to a newborn.

We use D10 instead of D5 because of the difference in volume that we would administer. Because of their small body weight there is only so much volume a neonate can tolerate. Using D5 would require twice the volume of D10 to deliver the same milligram amount of dextrose.

We should never directly infuse higher concentration of dextrose like 25% and 50% in neonates. These concentrations have a high risk of vascular injury when administered via small veins. 12.5% is the maximum recommended concentration for peripheral administration.

3. Alligation

A provider might occasionally request a 12% dextrose solution when a neonate is not responding well enough to a D10 infusion. Though commercial preparations are available, in my experience it is not routinely stocked because it is not frequently used.

This is one scenario where knowing how to perform alligation calculations is important. Alligation uses a higher concentration of dextrose like D25% or D50% to compound a lower 12% solution.

I explain 2 ways to perform alligation:

How to Perform Alligation Calculations: Grid Method

Alligation Calculations Made Easy using Intuitive Equations

An illustration of an alligation table, featuring labeled sections for diagonal, vertical, and horizontal calculations, along with images of beakers and a graphical representation of formula elements.
A diagram illustrating the alligation equation with variables CQ1, CQ2, and CQ3, set against a green background.

Discover which approach works best for you.

If this unit has been helpful, I would love to hear from you! Leave a question or comment below.

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

CRRT: What You Need to Know for Patient Care

Continuous renal replacement therapy (CRRT) is a lifesaving procedure that requires a high level of skill, well established procedures and a multidisciplinary approach for safe execution. Here are 6 things you need to know if you provide care to patients receiving CRRT.

What is CRRT?

CRRT is a continuous form of dialysis indicated for patients with acute kidney injury. Intermittent hemodialysis and CRRT both work by removing a portion of patients’ blood from the body, running it across semipermeable filters to remove toxins (like urea) and returning it to the patient.

Both procedures use a dialysate fluid which runs in the opposite direction to blood flow. This creates a diffusion gradient across the semipermeable filters allowing extraction of toxins into the dialysate fluid which is collected as waste.

Dialysate fluid mimics the natural composition of plasma. It contains purified water, electrolytes and dextrose.

Diagram illustrating a dialysis filter with a semi-permeable membrane, depicting the flow of blood, dialysate fluid, and waste management.

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When is CRRT Preferred?

The blood flow rate in intermittent dialysis is as high as 300-500ml/min. CRRT flow rates are 150-250ml/min.

The lower flow rate results in softer fluctuations in blood pressure.

CRRT therefore has the most benefit in patients who are hemodynamically unstable.

These are patients who already require a large quantity of vasopressors to maintain arterial pressure and would not tolerate large volumes being removed from systemic circulation.

CCRT is also the preferred form on dialysis when a patient is fluid overloaded particularly with cerebral edema where rapid correction of systemic volume will worsen outcomes.

Because CRRT is running 24/7 it means that all other aspects of your patient’s care will be affected. Ideally, there will be stringent policies and procedures established for the use of CRRT at your facility but quite honestly that is not always the case.

Where’s what you need to know to advocate for safe patient care. Let’s start with medications and CRRT.

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CRRT: Medication Dosing & Administration

Be sure that all your medications have been reviewed by pharmacy for accurate dosing in patients receiving CRRT.

Appropriate drug dosing in CRRT is drug specific, indication specific and patient specific.

It requires consideration of the drugs mechanism of action and whether it is highly protein bound or not.

It is also specific to the unique flow rate and filter used for CRRT.

Even with all these considerations dosing is not a one and done deal. It has to be reevaluated as the patient’s clinical condition improves or worsens.

Infographic listing critical medications affected by continuous renal replacement therapy (CRRT), including antibiotics, anticonvulsants, vasopressors, analgesics, and sedatives.

Antibiotics require significant consideration of the organism being targeted and the sensitivity of the organism to the drug. Both overdosing and under-dosing are potential risks with CRRT.

Sedatives, analgesics, vasopressors and anticonvulsants will all be affected by the use of CRRT. In some cases, you will note higher doses than usual and in some cases a dose reduction will be required.

In short, run all medication changes by your pharmacist.

CRRT: Associated Risks to Monitor

There are significant risks associated with CRRT. You need to know what to look out for while providing patient care.

Infographic illustrating five key monitoring aspects of Continuous Renal Replacement Therapy (CRRT) including blood pressure, clotting, bleeding, electrolytes, and temperature.

1.Clotting

Clotted filters and tubing are the number one reason for interruptions in CRRT. The most common cause being inadequate anticoagulation.

The coagulation cascade will be activated any time blood contacts foreign objects including the tubing and filters of the dialysis machine. Therefore, an anticoagulant either heparin or calcium citrate must be used during this process.

Here’s what you do:

Monitor for visible clot formation, which is most common during initiation of CRRT at the point of venous access, in the tubing and at the filter.

2. Bleeding

Anytime anticoagulation is used there is an increased risk of bleeding. For CRRT either heparin or calcium citrate will be used as anticoagulant. While heparin does have a higher risk of bleed relative to calcium citrate, using citrate has its own risk like hypocalcemia and electrolyte disturbances that can be significant in a patient who is already critically ill.

There are also patient specific risk factors like thrombocytopenia that increases the risk of bleed.

Here’s what you do:

Monitor lab values like hemoglobin, hematocrit, platelets, apTT for heparin and any visible signs of bleeding.

3. Temperature

Hypothermia can occur in up to 50% of patients receiving CRRT.

Body temperature is strictly regulated at around 98.6 F. During CRRT, blood is being removed from the body, ran through a machine at room temperature and returned to the body, all of which drops the temperature of blood.

In a patient who is already very sick hypothermia can have significant medical impact. It increases oxygen requirements, causes arrythmias, ischemia, clotting dysfunction and much more.

Here’s what you do:

Most protocols recommend hourly checks of temperature and continuous monitoring if temperature drops below normal. There are blood warming devices that can be used with CRRT machines. These will warm up the patient’s blood before it is returned to the body.

External warming with blankets, warming blankets, heating pads can also be used to raise the core temperature.

4. Electrolytes

All forms of dialysis are associated with electrolyte disturbances.

The kidneys play a central role in maintaining electrolyte balance. The use of dialysate fluid that mimics the physiological concentrations of electrolytes attempts to compensate for this function. However, dialysate fluid is not dynamic in response to physiological changes.

This places the patient at risk for both supra and sub physiological levels of electrolytes with consequences ranging from cardiac and muscle dysfunction, cerebral edema and neurological dysfunction.

The selection of dialysate fluid plays a major role in minimizing the occurrence of electrolyte disturbances. This is one of the complexities that requires a highly trained team to prescribe optimal fluids on a patient specific basis. It requires correlation between the formulation of the dialysate, the patient’s baseline electrolyte status and choice of anticoagulant.

What you should do:

All CRRT patients should have their electrolytes monitored at least every 12hrs. This includes sodium, potassium, chloride, magnesium, calcium, phosphate, and bicarbonates.

5. Blood Pressure

The major advantage of CRRT is the hemodynamic stability offered by the slow rate of filtration. However, hypotension is still a very real concern. This should be continually monitored in the critical care setting where CRRT will be performed.

I hope this provides you with a solid foundation to advocate for yourself and your patients receiving CRRT. While we all cannot be experts in CRRT as a requirement for patient care, knowing what questions to ask and what to monitor as the bedside provider of care can save lives.

The National Kidney Foundation offers a deep dive into the complexities of CRRT.

Think you got it? Take the CRRT Quiz!

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

Administering TPN: 4 Things You Need to Know

Whether you’re administering TPN (total parenteral nutrition) or a pharmacist compounding it you are going to ask or be asked about these 4 things at some point.

How we dose TPN is dependent on lots of factors like the level of care (ICU versus medical), organ dysfunction and body composition to name a few. But these 4 concepts concerning administration apply across the board.

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1. Central vs Peripheral Administration

With TPN we are administering the patient’s nutritional needs intravenously, completely bypassing the gastrointestinal tract. Intravenous administration can be either via a central line or a peripheral line.

Almost always, a patient requiring TPN will need a central line.

Simply put, a central line connects into large veins while peripheral lines terminate into smaller veins that are closer to the skin surface.

Illustration comparing central and peripheral lines for TPN administration, showing a hand with a peripheral line and a torso with a central line connected to an IV bag.

Osmolarity

Illustration showing the major components of a TPN with dextrose, amino acids, lipids and electrolytes displayed in a bag for intravenous administration.

The 3 main components of TPN are amino acids, dextrose and fats. TPN is prepared and administered in 1 of 2 ways:

  • 3 in 1: amino acids, dextrose and fats are prepared in a single container and administered together
  • 2 in 1: amino acids and dextrose are prepared in a single container and administered together. Fats are administered separately.

The deciding factor for central versus peripheral administration is osmolarity. Osmolarity is a measure of concentration. Most TPN will have a high osmolarity that exceed 900 mOsmol/L because of the dextrose and amino acids it contains.

Administering high osmolarity medication into a peripheral vein creates an osmotic gradient that pulls fluid from the tissues surrounding the vein. This causes inflammation (phlebitis) and extravasation (drug leaks out of damaged vein and into surrounding tissue). The immune response to tissue damage causes in influx of inflammatory mediators that can initiate clot formation in an attempt to limit damage to the vein. This increases the risk of clot formation (thrombophlebitis).

Administration hyperosmolar solutions like TPN via central rather than peripheral vein allows for dilution and a subsequent lower risk of vein irritation, phlebitis, extravasation and thrombophlebitis.

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Types of Central Lines

The most common central line for TPN administration is a PICC (Peripherally Inserted Central Catheter) line. As the name implies, the point of entrance is a peripheral vein, but it terminates into a large central vein. PICC lines are appropriate for acute care and short to intermediate term administration of TPN.

Patients requiring more long term or permanent administration of TPN will require tunneled central venous access devices or implanted ports that have a lower risk of microbial migration and infection with long term use.

2. In Line Filters

All TPN will require a filter for administration. The filter and administration tubing should be changed every time you change the bag or every 24 hours (whichever comes first).

A filter is necessary to reduce the patient’s exposure to microprecipitation, microparticles, microorganisms, fungi and air emboli.

The current recommendation is for all parenteral nutrition be filtered with a 1.2-micron filter.

Placement of In-Line Filter

Image showing the placement of the in-line filter when administering TPN. The filter is placed below the Y site where the infusion meet

Where the filter is placed is very important.

It should be placed as close to the patient as possible not close to the bag.

When lipids are administered as a separate infusion, the filter should be placed below the Y site where the infusions meet.

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3. TPN Compatibilities

Ideally TPN should have a dedicated line for administration.

A catheter with multiple lumens, one dedicated to TPN with others available for other medications is ideal but not always possible.

Illustration of a multi-lumen catheter with multiple ports for intravenous access. Which is the ideal when a patient requires TPN

In short, nothing should ever run together with TPN for 2 main reasons:

Risk of Infection

TPN has a high concentration of dextrose which is a favorable environment for bacterial growth. We want to minimize manipulation of the line and minimize access to the port as much as possible to reduce the risk of bacterial transfer.

Each time that line is accessed to change from TPN to another medication is an opportunity for central line associated blood stream infections (CLABIs).

Precipitation

TPN is a very sensitive formulation. It is light sensitive, pH sensitive, temperature sensitive. Every exposure matters.

We would never run other medications through the same line as TPN because the combination can result in pH changes that cause precipitation of electrolytes like calcium and phosphates. The changes in pH that can occur when medications are combined is not easily measured.

These precipitates can occlude vessels in the pulmonary system causing embolism or pneumonitis.

Always advocate for a dedicated line for TPN administration. Often, providers are simply unaware of the risk of line sharing with TPN.

4. Discontinuation of TPN

TPN introduces a high dextrose solution right into the blood stream. This is very different to how glucose is introduced into the bloodstream when we eat (via the gastrointestinal tract).

Eating a meal results in a gradual rise and decline in blood glucose with a corresponding response in insulin release from the pancreas in an attempt to maintain normoglycemia.

Illustration depicting the rhythmic response of blood glucose and insulin release from the pancreas during periods of consumption and fasting.

With intravenous administration of TPN, dextrose enters the blood stream at a fixed rate. There is no fluctuation. The body responds with a steady release of insulin. There is no period of fasting.

Illustration depicting the relationship between dextrose infusion, blood glucose response, and insulin response in the context of intravenous nutrition.

If we suddenly stop TPN infusion the influx of glucose immediately stops but insulin release will remain elevated for a short period of time. The ratio of insulin to dextrose is very high for a period of time. Some patients can tolerate the abrupt discontinuation but, in some patients, this can lead to rebound hypoglycemia.

Because of this, we recommend titrating patients off of TPN by decreasing the rate by half for 1-2 hours before discontinuation. This allows the pancreas time to decrease the levels of insulin circulating in the blood.

If there is a sudden unplanned interruption in the supply of TPN, 10% dextrose solution should be infused at a rate equal to the TPN infusion. This can occur if there is a delay in delivery from pharmacy, damage to the TPN bag, or if precipitation is noticed during infusion.

TPN preparation and administration can be complex and very patient specific but familiarity with these 4 pointers will improve patient safety across the board.

The American Society of Parenteral and Enteral Nutrition (ASPEN) provides clinical guidelines and standards for all aspects of nutrition.

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

How to Land Your Recommendations to Medical Providers: Steal My Script!

Communication is essential for the success of any relationship including medical teams. There is a clear emphasis on the importance of knowing what to recommend but not enough on how to make those recommendations to the team. Let’s fix that and focus on making effective recommendations to improve team relations.

Even with well-seasoned pharmacists, there can be frustration when recommendations are not accepted.

I urge you to not fall into that trap; it is helpful to no one.

Instead let’s focus on what we can adjust in our practice and perspective to improve patient outcomes through specific recommendations tailored to each situation.

Know Your Role

I have so much respect for physicians. They take on the responsibility of the whole patient: every organ, every drug, the social issues, insurance issues…all of it. They are the captains of the ship. We are part of the crew.

As pharmacists we are focused on the drugs. The provider must consider our recommendations against all those other issues and make a decision. They must do the same for recommendations from other specialists as well. We provide evidenced based recommendations; they make the decisions.

When I consider the immense liability that physicians assume, it calms any frustrations I may feel when a recommendation is not accepted. There may be factors that are not apparent from my perspective.

With that said, the reason for rejection could also be the approach. Let us consider 3 ways to refine your presentation of interventions and potentially improve the acceptance of recommendations.

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Be Helpful, Provide Value

You will never fail in any aspect of life if you show up ready to be helpful and add value. Knowledge does not inherently provide these qualities; you must pursue them. Don’t wait to be called on, find ways to contribute to the discussion. This is how you build trust and show competency.

Here are 3 ways to proactively engage the team and improve your rate of acceptance.

  1. Recommend high quality resources that supports their current discussions. This can be an infographic, a website or you can offer to put together a handout for the team that can serve as a quick reference. Provide something that is specific to your facility and of course relevant to their practice.
  2. Offer to present on an atypical disease state that the team is working on. You can present while they have lunch in their office or breakroom. It does not have to be formal.
  3. Offer pharmacy services as appropriate:

“I can take care of the warfarin dosing“

” I can show you how to order a pharmacy consult for almost anything you need help with“

You want to figure out very specific areas the team will come to rely on your recommendations. For instance, always be ready to provide days of therapy for antibiotics. Always review cultures and sensitivity, always renally dose medications. Over time, with consistent performance in those areas, the team will see you as an invaluable part of the team because of these very clear expectations.

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Ask Questions

Ask questions, even when you know the answer. Asking a question is one of the main ways that I offer up recommendations. Even if I am certain that a specific intervention is appropriate, I bring it up as a point of curiosity rather than a request. This questioning approach leads to more productive recommendations.

Dr Jacobs, would this be a situation where de-escalation to nafcillin would work since the culture results show MSSA?

With this question, I made the recommendation, provided the reasoning and the solution. But I also gave the provider bandwidth to engage in discussion versus:

We should switch the patient to nafcillin since its MSSA.

The discussion generated from asking questions helps to build relationships and places the decision-making power where it needs to be, in the hands of the physician.

State Your Intent Before Giving a Defense

Mr. Roger’s medication history shows that he has never taken narcotics in the past. Right now, he’s on oxycodone 10mg PO every 4 hours scheduled with 4mg morphine every 2 hours as needed for pain from his broken femur. Today is day 10. Do we need to scale back his opioids in preparation for discharge?

While all the information provided is helpful it leaves everyone wondering where this train of thought is leading. Instead, place the recommendation up front so that the details provided can be interpreted with respect to that recommendation.

The recommendation here could also have been to assess bowel movements and add stimulants or about the risk of respiratory depression. The teams mind could be going in many different directions. Here’s what I would say instead:

Do we need to scale back on Mr. Roger’s pain medications in preparation for discharge? Today is day 10 post op for a broken femur. He is on oxycodone 10mg PO every 4 hours scheduled with 4mg morphine every 2 hours as needed for pain.

With this approach everyone is on the same train of thought and heading in the same direction. This small change in presentation of your recommendations will improve your rate of acceptance.

Graphic illustrating key principles for building trust within medical teams when making recommendations: 'Know Your Role', 'Be Helpful, Provide Value', 'Ask Questions', and 'State Your Intent Before Giving a Defense' with a blue and green color scheme.

Rounding vs. Calling

There is a distinct difference in approach when you are rounding with the team versus when you are calling a provider. Rounding is conducive to back-and-forth discussions. It has a benefit of body language, eye to eye contact and everyone there is keyed in on the same patient at the same time.

Illustration comparing medical rounds with a team of healthcare professionals on the left and a doctor on a phone call on the right.

Some of the strategies we’ve already discussed would not fare well when calling a provider to make a recommendation.

When you call a provider there is no telling what they are currently engaged in. They could be with another patient, at home with family, dropping their kids off to school (they have lives too!). They may not have convenient access to the patient chart.

When calling a provider, I recommend a more straightforward approach. Be concise as possible. Immediately state your recommendation clearly:

  1. who you are
  2. the patient you’re calling about
  3. the concern
  4. the recommendation

Dr Jacob’s, this is Marsha from pharmacy. I am calling about Mr Combs in 946. I have the order for insulin lispro ACHS. This patient is NPO, can we change that to Q4H?

Unlike rounding, here I am providing enough relevant information for a yes or no answer. If a change in therapy is going to be made, always emphasize who will change the order. I always offer to initiate the change, again, because I have no idea what they are up to.

What you say and how you say it matters when interacting with the medical team. Take some time to evaluate your approach. If you don’t have an approach, build one! The strategies for effective recommendations provided here are a great way to start.

If you’ve found this unit helpful, we would love to hear from you! Share some of your strategies for landing your recommendations in the comments!

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

How to Dose Vancomycin: 3 Kinetic Values You Need to Know

…and what to do with them

Confidence in dosing vancomycin comes from a solid understanding of vancomycin kinetics. It’s not as complicated as it seems.

I will walk you through the 3 key kinetic parameters needed to dose vancomycin:

  • Elimination Rate Constant: Ke
  • Half Life: T 1/2
  • Vancomycin Trough & AUC

We’re not going to go back to class. We know how to get these values by dosing calculators or manual calculation. Instead we are going to focus on how to interpret and analyze these values.

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Population vs Patient Specific Kinetics

When we initially dose vancomycin we are using population kinetics. This means that we make assumptions about how the patient will metabolize vancomycin based on demographics like their age, weight and renal function because that’s how others with similar demographics metabolized it.

Illustration comparing population kinetics and patient specific kinetics for vancomycin dosing, featuring icons of groups of people and a magnifying glass.

Once our patient has received some doses of vancomycin we can draw levels to then calculate patient specific kinetics.

This will allow us to tailor the regimen to our patient’s unique processing of vancomycin.

Let’s start with the elimination rate constant (Ke).

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Vancomycin Ke

The elimination rate constant for vancomycin (Ke) is simply the amount of drug that is cleared from the body per hour.

Using Ke we can estimate the amount of drug that is present in the body after a specific period of time (T) by the equation: e-Ke(T)

The first Ke we use will be based in population kinetics using renal function. Simply put, most patients with a creatinine clearance (CrCl) of ‘x” will eliminate vancomycin at a rate which is calculated as:

Illustration of the elimination constant (Ke) formula for vancomycin dosing, featuring a modern, graphic design with highlighted equations.

This is simply an estimate. Because CrCl is affected by many variables (weight, age, Scr, gender) 2 patients with the same value for creatinine clearance can look vastly different and metabolize vancomycin differently. There are also variations in terms of using actual body weight versus adjusted body weight for calculations of creatinine clearance. Population kinetics calculations simply provide a starting point.

We need to know Ke because it estimates how quickly vancomycin is being cleared so that we can determine when the next dose of vancomycin should be given to maintain high enough drug levels.

We do this by using Ke to determine half life (T 1/2) of vancomycin.

Vancomycin Half Life (T 1/2)

The half life of any drug is the amount of time needed for the concentration in the body to fall to 50%.

Using Ke, half life is calculated as:

Illustration detailing the half-life of vancomycin (T 1/2) and elimination rate constant (Ke), featuring text and a simple color gradient background.

We are using Ke estimated from population kinetics, therefore this half life will also be a population estimate.

0.693 is a constant that is assumed in vancomycin clearance. It assumes that vancomycin is cleared from the body in fixed proportions. This is referred to as first order clearance. It gives us a window of time, in hours, that we can use to determine the frequency of dosing.

As a general rule, the frequency of dosing should be 1-1.5 times the calculated half life to achieve vancomycin drug concentration sufficiently high to be an effective antibiotic.

Vancomycin Dose

Once we have a frequency with which to dose, we can select a dose. This is the most straight forward part. We have a range of 15-20mg/kg per dose. You will select any dose in that range that is available at your facility.

To calculate your initial Ke, half life, frequency and dose you can use dosing calculators like vancopk.com. Remember: no calculator or protocol overrides your clinical judgment. You are solely responsible for the tools you use to treat patients.

A calculator cannot account for patient specific details like paraplegia, cirrhosis or fluctuating renal function.

To learn what to do in those situations check out the unit How to Dose Vancomycin: When Dosing Protocols Fail.

These patients have confounding clinical features that are not considered by the standard dosing tools but places them at a higher risk of vancomycin accumulation and toxicity.

Once you’ve given your initial dose at your selected frequency we will draw vancomycin levels. These levels are what will transition us from population kinetics to patient specific kinetics.

After verifying a few details we will get to see exactly how our patient clears vancomycin.

Vancomycin Trough & AUC

Through my years of practice I have worked through the transition of vancomycin monitoring via trough only to area under curve (AUC). You can see the evidence for this change in practice here.

In summary, trough only monitoring is no longer recommended when using vancomycin. The rates of efficacy and the incidence of toxicity make it less favorable to using the AUC/MIC ratio.

You will still draw trough levels but you will use them for calculation of AUC instead of a direct measurement of therapeutic efficacy.

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How to Assess Vancomycin Levels

Before you make any decision based on levels you must assess the level for accuracy.

Infographic detailing the steps to assess vancomycin levels, including checking for missed administrations, checking proximity to dosing schedule, and timing of the level draw.

1. Were all vancomycin doses administered?

Were any administrations missed? This can occur due to patient refusal, missing medication, compatibility issues, patient being off unit at the schedule administration time or patient intolerance to name a few. Interpretation of your results with the assumption that all doses were given when they were not can lead to significant miscalculations.

2. Were doses administered close to scheduled times?

Vancomycin administrations are time sensitive. When doses are given late it will affect the kinetics. This is especially important with every 8 hour dosing. Deviation from the dosing schedule can result in effective Q6 dosing rather than Q8 which would sway the kinetics.

3. Was the vancomycin level drawn appropriately?

Was it drawn during infusion? Immediately after the dose? Is it a true trough?

Lab errors can occur. Do not change your dose without assess the timing of the level relative to administrations.

How to Adjust Vancomycin Dose

Now that you have patient specific data we can recalculate the Ke and T1/2 for a more accurate estimate for vancomycin clearance for your patient.

We may need to change the dose, change the frequency of dosing or both depending on a combination of the blood levels, recalculated kinetic parameters and severity of infection.

Graphic illustrating how to adjust vancomycin dosing with three colored sections indicating when to change dose, change frequency, or change both dose and frequency.

1. Change the Dose

In general if you are close to goal AUC/trough you would increase the dose keeping all other factors the same.

2. Change the Frequency

If you need to double your levels to get to goal then you likely need to increase your frequency especially in serious infections like endocarditis, bacteremia and osteomyelitis.

If I increase my frequency from Q12 to Q8, more often than not, I am also going to drop my dose as well to proactively provide some buffer against variances in clearance that can lead to rapid accumulation.

The benefit of Q8 dosing is that we can get to steady state within 24 hours. Which means we can quickly increase the dose if needed while minimizing toxicity.

3. Change Dose and Frequency

Some patients in high metabolic states like cancer and trauma patients tend to clear vancomycin rapidly.

If your vancomycin level returns low (like less than 5) after verifying administration and lab times you may need to increase both factors to get to therapeutic levels.

Final Thoughts

Don’t spend weeks trying to get to goal vancomycin levels. A patient with a persistently low levels of vancomycin is effectively receiving no therapy while also increasing the risk for mutation of bacteria to vancomycin resistant species.

Using these strategies will guide you to make wise decisions that will get you to goal, minimize toxicity and improve patient outcomes.

Share some of your experiences with dosing vancomycin in the comments!

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

4 Proven Strategies to Avoid Mistakes with Pediatric Patients

Let me save you the heart ache of a medical error in a neonate or pediatric patient. Understanding how to prevent common pediatric medication errors is crucial in safeguarding our youngest patients.

This isn’t a discussion of how to determine appropriate dosing in infants and pediatric patients. We have many reliable and established resources like Neofax and Harriet Lane that provide evidenced based dosing recommendations in this population.

The greater concern is all the potential pitfalls that can occur in the process of getting that recommended dose to the patient from calculations and compounding to administration. The hazards of this execution are not talked about enough. Let’s change that.

Why Pediatrics are High Risk

Neonatal and pediatric patients are at a higher risk (31%) of medical error than the general population (13%)for several reasons including:

1. Lack of Medical Research

There are unique challenges to conducting research in non – adult patients. Children cannot provide consent. Parents or legal guardians make the decision for them. There must be consideration of a child’s emotional and physical maturation to handle to rigors of a clinical trial. Is it ethical?

Reasons why pediatric and neonatal patients need special considerations to prevent medication errors
2. Rapidly Changing Bodies

Unlike an adult, a child’s body systems are in an active state of maturation.

The stomach pH at 2 months old is very different than at 6 months.

Likewise, skin composition is very different at 12 months versus 24 months.

Water and fat composition also varies as children mature.

Also, liver and kidney function increases as the child develops.

All of these moving targets will affect how a child will respond to medication as they age.

3. Lack of Standard Dosing

Children undergo significant physical and metabolic changes as they mature. Because of this, dosing is usually calculated as a factor of body weight or body surface area. This necessitates calculation of doses. Whenever there are calculations there is a risk of error.

4. Medication Compounding

Non-standard or weight-based dosing means that medications will likely need to be made; another opportunity for error. Selecting the right starting ingredients, at the right concentrations and volumes and combining together with appropriate technique are all steps that can introduce medication errors in pediatric patients.

5. Communication Gap

Kids are less able to communicate and associate the way they feel to medical intervention. Caregivers may misrepresent or all together miss adverse events.

The need for specific investigation into drug development for non-adults has been gaining much attention. The Best Pharmaceuticals for Children Act incentivizes research that  improves safety and efficacy of medications use by children. Since 2002 they have conducted 51 pediatric trials and updated 23 drug/device labels to reflect best use in the pediatric population.

While policies change at an administrative level, here are 4 areas to be mindful of in your practice to prevent medication errors in neonatal and pediatric patients.

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1. Reasonable Weight

Dosing weight errors in non-adult patients are very common. The most common cause for error is discrepancies between pounds (lbs) and kilograms (kg) and decimal errors.

All drug dosing recommendations from reputable sources will be reported in kilograms. However, the general Western population is more familiar with weight in lbs.

Pop Quiz

A typical scenario is a patient being weighed on a scale that results as lbs or the caregiver reports the weight in lbs but it is transcribed into the chart as kg.

For example, a patient who weighs 7lbs is documented as weighing 7kg (a 2.2x increase in weight).

How close scrutiny of patient weight can help to prevent medciation errors in neonatal and pediatric patients

A decimal error can result from a weight being entered as 23kg instead of 2.3kg.

What can you do to prevent these weight-based medication errors?

Have a reasonable expectation of weight

Always consider the weight relative to age in pediatric patients. Have a general idea of weight for pediatric patients at landmark ages. If a patient varies significantly in weight than expected it is worth investigating and verifying prior to dosing. This could prevent significant medication errors in the pediatric population.

Infographic displaying the reasonable weight by age for pediatric patients, highlighting weights for newborns, 12 months, 4 years, 9 years, and 14 years. Knowing these benchmark for typical weight can help prevent medication errors.

The Joint Commission recommendation for avoiding weight based errors in pediatric patients:

Kilograms should be the standard nomenclature for weight on prescriptions, medical records and staff communications.

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2. Emergency Response

The inherent risks in pediatric healthcare are amplified in emergency situations.

To be prepared familiarize yourself with the Braselow Tape.

How the Braselow tape can help prevent medication errors in neonatal and pediatric patients

The Braselow Tape is a color coded “tape” that is placed along the length of a child to determine their “color zone”.

Each zone is represents an estimate of their weight and length with corresponding pre-calculated doses and equipment sizes that would be most appropriate.

It eliminates the need for non-standard dose calculations during the most acute phases of pediatric emergencies which helps to prevent medication errors.

3. Independent Double Check

As the name implies, a double check should always be done with pediatric calculations. The independence needs to be emphasized.

It is NOT a double check of your calculations. They are performing their own calculations without the influence of your work.

Graphic illustrating the concept of 'Independent Double Check' in pediatric calculations, featuring a person calculating with a calculator on one side and another person with a notepad and calculations on the other, emphasizing the importance of independent verification in medical dosing.

Each person should perform calculations as if they received the initial order. Do not show them your work, do not share your thought process or final answer prior to their independent calculations.

If both of you do not arrive at the same value, I recommend having a 3rd practitioner independently perform the calculations to identify and prevent a potential medication error.

The unit on alligation calculations which are regularly used in neonatal and pediatric populations to compound specific fluid concentrations is a useful resource for those working with this population.

Use dosing calculators from reputable sources like LexiDrug Pediatrics or Micromedex Pediatrics to assist with calculations.

4. Per Day vs Per Dose

Some drug references will provide dosing recommendations per day or per dose or both. Penicillin is an example where the dose is provided as per day and per dose within the same drug reference based on indication.

Be mindful of this. Always double check the units of the recommended dose.

Pop Quiz

Providing medical care to neonatal and pediatric patients requires a high level of preparedness, diligence and intention. I hope this unit has provided you with some guidelines to help standardize your approach and avoid these potential pitfalls.

Share your near miss errors in the comments. Let’s learn from each other!

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.

3 Ways to Maximize Your Study Sessions

Studying is like a sport. There should be demonstration of correct technique, lots of consistent repetition and game day. Yes, every one has different study styles but these 3 techniques can help just about anyone improve their study experience and get more out of their study time. Let me explain.

For most, study skills are never taught. You just figure it out. The truth is you’re always “figuring it out” as the topics, professors and expectations evolve. These are the 3 best study habits that will provide a framework to help you become a high performing “academic athlete”. When you adopt this framework, you will certainly improve study habits.

1. Curiosity & Exploration

This is where all interests start, with curiosity and exploration.

Often, what you hear instead is to just jump right in. So you attempt to read, understand, memorize and analyze all at the same time. That is simply not how the brain works, it’s mentally exhausting. Part of the strategy for successful studying is the ability to sustain until game day. Here’s what works.

How to improve study outcomes with your first study session

It’s like going on a first date, you’re there for a vibe check. There are no grand expectations.

How the first encounter goes decides how you will show up for subsequent dates.

Likewise, the first time you engage with study material, read through the content, section by section, with very little expectation to understand or memorize.

You are simply trying to get an overview of the content. You want to orient yourself to what the topic is and gain some familiarity with the material.

This will make it easier to apply higher levels of thinking like analysis and application when you revisit the content. It also tames the feeling of overwhelm that often occurs when you encounter a large amount of new information. All of which will improve your study process and skills.

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2. Never Attend Lecture without Prep

If you want to orient yourself for maximum efficiency with your study time you should never show up for a lecture without having covered the basics about the topic. Good preparation beforehand can tremendously improve study efficiency.

Lecture details may not be available but you can read a text or watch a video beforehand. If you are hearing the basics for the first time as it leaves the lecturer’s mouth you are wasting time.

How to use lectures as a way of improving your study sessions

Lecture is an opportunity for you to ask pointed questions. This is how you transform a broad lecture into one that is customized for your specific needs. That cannot be done without running though the material in advance.

Lecture should be a time of intentional, active listening to gain clarity and build on what you already know. You should be adding structure to an established (even if shaky) foundation. You should execute curiosity and exploration of the material before attending lecture. It is one of the best habits to improve your study skills.

Building the habit of preparation will continue to serve you as a practicing clinician.

3. Zone in on Subheadings

Subheadings are not just a stylistic approach to writing. They usually represent the intent of that section, essentially providing focus to improve your study sessions.

This is the main idea, the key concept you should be able to recall and analyze by the end of the section. It gives you a goal as you work through the material. It turns studying from passive to a specific and active pursuit.

At the end of each section look back at the subtitle and ask yourself:

Can I summarize the content of this section around the title of the subheading?

If not, then reread because you’ve missed the main idea.

Summary of 3 strategies to improve study sessions

The Academic Athlete

I’m not a sports enthusiast but the comparisons between an athlete’s preparation and that of a student are persuasive .

When you first learn a new sport, or a new play you don’t jump right in and execute. The first step is to observe and get an overall sense of what is required of you. You become familiar with the rules and the process (curiosity/exploration). Based on that you come up with a strategy to execute. You work out any kinks or confusion (lecture/questions). Then you drill over and over again until gameday.

A high performing athlete optimizes sleep, nutrition and exercise. A high performing student should do the same. A high performing athlete values preparation, so should a high performing student.

A mindset shift to that of an academic athlete together with these 3 steps will improve study skills.

If you’ve found this unit helpful, I would love to hear from you! Leave a question or comment below.

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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.