1st E-shift post!

Hi everyone,

Here is an example of an E-shift post. These are 4 clinical questions that came up recently, so I turned them into an E-shift post so you all can see what I’m expecting you to do during your E-shift.

1. Is it ok to do a rectal temp in patients with neutropenic fever?
Tintinalli says “Digital rectal examination is relatively contraindicated in neutropenic patients and should be withheld until after initial antibiotic administration” but doesn’t specifically comment on whether it’s ok to check a rectal temperature or not. This is important as many febrile patients (especially our pediatric patients) receive a rectal temperature measurement. The answer is NO, you should not check a rectal temperature in a neutropenic patient. A problem with this may be that you will not have the CBC back when you order a rectal temperature to be done, so keep a high index of suspicion and try to predict who may be neutropenic, and withhold any rectal exams/temps until the CBC returns, i.e. a cancer patient who is on a chemotherapeutic agent known to cause neutropenia. Neutropenic patients should have an oral or an axillary temperature taken.

2. In a patient with a supratherapeutic INR due to warfarin therapy whom you are going to treat with vitamin K, does it matter if you give the vitamin K orally or IV? During a recent shift, I had to give vitamin K to a patient with a supratherapeutic INR and guaiac (+) stools. The question arose regarding routes of administration and whether it was better to give the vitamin K IV or po. An article in the March 2013 issue of Transfusion (“Clinical experience with oral versus intravenous vitamin K for warfarin reversal”) found that IV vitamin K lowered the INR significantly faster than po vitamin K. Recommendations for warfarin reversal from the American College of Chest Physicians recommend an oral dose for nonbleeding patients only if the INR exceeds 10 and IV dosing for bleeding patients either at a dose of 5 or 10 mg. Based on these reports, the IV route had a more rapid onset of action and a minimal dose of 1 mg is appropriate but it remains unclear whether higher doses by either route are more efficacious. I think the take home point is that if you require more rapid reversal, IV is the way to go, but dosage remains debatable.

3. In patients that are being admitted for cellulitis, do blood cultures need to be routinely obtained? Usually, when I am admitting someone for cellulitis (i.e. the cellulitis is > 50% of one limb, the patient failed outpatient therapy, patient has SIRS criteria, etc), I tend to obtain blood cultures. But I wonder if this is useful or if it changes management. A study in Clinical Infectious Diseases (“Cost-Effectiveness of Blood Cultures for Adult Patients with Cellulitis”) had the following results: “the yield of blood cultures is very low, has a marginal impact on clinical management, and does not appear to be cost-effective for most patients with cellulitis.” In this study, of 710 blood cultures obtained, in 11 cases (2.0%) was a significant patient-specific microbial strain isolated, and in only 8 cases did they effect treatment of the patient. They found that risk factors for bacteremia included: age >45 years; shorter duration of symptoms before physical examination; higher incidence of fever; temperature ≥38.5°C at admission; and WBC count >13,300/mm³ at admission. It would probably be safe to withhold blood cultures in patients admitted for cellulitis unless they have one of the above risk factors.

4. What is the best way to anesthetize a patient prior to incision and drainage of an abscess? The answer to this question was surprisingly difficult to find, and it doesn’t appear that there have been any studies directly comparing different ways of anesthetizing a patient. It does seem, however, that we often do not do a great job at pain management prior to and during I+D. Use of a local anesthetic is recommended, specifically to inject lidocaine into the dome of the abscess with the syringe held parallel to the skin and rotated to distribute the anesthetic circumferentially. Do not inject the lidocaine directly into the abscess; this causes more pain as the pressure within the abscess increases, and the acidic environment of the abscess inactivates the lidocaine. We should also be more liberal with giving patients IV pain medications prior to the procedure. Conscious sedation should also be considered for large abscesses or young patients. Anecdotally, I often give my patients 1mg of Dilaudid and 1mg of Ativan IV prior to the I+D and I haven’t had any complaints from my patients when I do this. I was hoping to find some studies about the use of ice packs or topical anesthetics (ex. LET) but couldn’t find anything.

I hope you all learned something, I’m looking forward to reading about everyone’s E-shifts!

Messman