• Cardiology (ACS, heart failure, arrhythmias)
• Infectious disease (sepsis, pneumonia, UTI)
• Renal/electrolytes (AKI, CKD, fluid management)
• Endocrine (DKA, thyroid storm, hypoglycaemia)
• Neurology (stroke, seizures, meningitis)

---

🏥 Ward Round - Bed 7, Medical Ward

---

Presenting Complaint

---

Background History

• Ischemic heart disease (previous MI 4 years ago)
• Type 2 Diabetes Mellitus
• Hypertension
• CKD Stage 3a (baseline creatinine ~130 µmol/L)

---

Current Medications (on admission)

• Metformin 1g BD
• Amlodipine 5mg OD
• Ramipril 5mg OD
• Atorvastatin 40mg ON
• Aspirin 75mg OD

---

Observations on Admission

• BP: 158/94 mmHg
• HR: 102 bpm (irregular)
• SpO₂: 91% on air
• RR: 24/min
• Temp: 36.8°C

---

Over to you, Dr. Afzal...

---

📋 Investigations - Mr. Tariq, Bed 7

---

A few prompts to guide your thinking...

---

✅ Point 1 - BNP & Acute Decompensated Heart Failure

• BNP <100 = HF unlikely
• BNP 100-400 = grey zone
• BNP >400 = HF very likely

---

⚠️ Point 2 - Metformin & Ramipril

Metformin:

• eGFR >45 = continue at full dose
• eGFR 30-45 = reduce dose + review regularly
• eGFR <30 = STOP (lactic acidosis risk)

Ramipril - this needs a challenge! ⚡

• In acute decompensation with AKI + hyperkalaemia risk → hold temporarily
• Once stabilised, fluid-overload resolved, renal function improving → restart and potentially up-titrate

---

⚠️ Point 3 - AF and Anticoagulation

Current guidelines (ESC/NICE) prefer DOACs over Warfarin for non-valvular AF:

---

🎯 Summary of Immediate Medication Actions:

---

1. What is his CHA₂DS₂-VASc score based on the information we have?
2. What IV diuretic dose would you start him on?

---

CHA₂DS₂-VASc Score - Mr. Tariq

---

🔢 Total Score: 4 / 9

---

What Does Score 4 Mean?

---

✅ Decision: Anticoagulate Mr. Tariq

Drug Choice - Apixaban is preferred here:

⚠️ Apixaban Dose Reduction Rule (ISTH criteria):

• Age ≥ 80
• Weight ≤ 60 kg
• Creatinine ≥ 133 µmol/L

---

🎯 Teaching Point

Always calculate CHA₂DS₂-VASc before choosing the anticoagulant, and always check renal function before dosing the DOAC. These two steps together prevent both under-treatment (stroke) and over-treatment (bleeding).

---

---

🏥 Ward Round - Bed 12, Medical Assessment Unit

---

Presenting Complaint

---

Background History

• Epilepsy (diagnosed 12 years ago)
• Hypertension
• Hypothyroidism
• Non-smoker, no alcohol

---

Current Medications

• Phenytoin 300mg ON
• Levothyroxine 100mcg OD (morning, fasting)
• Amlodipine 10mg OD
• Lisinopril 10mg OD

---

Observations on Admission

• BP: 182/110 mmHg
• HR: 88 bpm (regular)
• SpO₂: 96% on air
• RR: 18/min
• Temp: 37.2°C
• GCS: 13/15 (E3 V4 M6)

---

Over to you, Dr. Afzal...

---

🧠 Step 1: First Impression - What's Going On?

• Confused (GCS 13 - not fully alert)
• Severely hypertensive (182/110)
• Had a seizure en route
• Known epileptic on Phenytoin
• Headache + vomiting for 12 hours

---

🚨 Red Flags in This Case

1. Hypertensive encephalopathy
2. Subarachnoid haemorrhage (SAH)
3. Intracranial bleed
4. Phenytoin toxicity
5. Breakthrough seizure due to subtherapeutic levels

---

🔬 Step 2: Investigations - What & Why

Immediate (Bedside):

Urgent Bloods:

Imaging:

---

💊 Step 3: The Pharmacist's Eye - Medication Review

Phenytoin - 4 Key Questions:

1. Is her level therapeutic? (target: 10-20 mg/L)
2. Any recent changes in dose, formulation, or brand? (Phenytoin is narrow therapeutic index - brand switching matters!)
3. Drug interactions? - Phenytoin is a major CYP450 inducer
4. Toxicity signs? - nystagmus, ataxia, confusion, drowsiness

Levothyroxine:

• Hypothyroidism itself can lower seizure threshold
• Is she taking it correctly? (fasting, 30-60 min before food)
• Phenytoin induces metabolism of T4 - she may be underreplaced despite 100mcg dose

Lisinopril + Amlodipine:

• Both are antihypertensives - yet her BP is 182/110
• Is she non-compliant? Or is the BP this high because of the acute event?

---

🎯 Step 4: The Two Key Clinical Questions Right Now

• Toxic → reduce/hold dose
• Subtherapeutic → load with additional Phenytoin or switch

• If hypertensive encephalopathy → cautious BP lowering (reduce by ~20% in first hour)
• If reactive to seizure/pain → treat the underlying cause first

---

📋 Summary so far

Mrs. Nadia = Confused + Seizure + Severe Headache + BP 182/110
                        ↓
         Rule out: SAH / ICH / Hypertensive encephalopathy
                        ↓
         Check: Phenytoin level + CT Head URGENTLY
                        ↓
         Pharmacist priorities: Phenytoin level, drug interactions,
         BP management strategy, Levothyroxine adequacy

---

---

⚠️ Gentle Challenge

Levothyroxine causing hypertensive crisis?

---

The Antihypertensives?

• Non-compliance (missed doses?)
• Acute neurological event driving BP up reflexively
• Phenytoin interaction - more on this below 👇

---

💡 The Real Drug Interaction to Think About Here

Phenytoin + Antihypertensives:

---

🧠 More Likely Causes of Her Hypertensive Emergency

---

🎯 Teaching Point

As a clinical pharmacist, your role is to identify drug interactions that reduce therapeutic efficacy - in this case, Phenytoin reducing Amlodipine levels is a real and clinically relevant interaction that may be contributing to poor BP control.

---

"Hyperdense area noted in the basal cisterns. Appearances consistent with subarachnoid haemorrhage. No midline shift."

---

🚨 This changes everything!

---

✅ You're Correct - BP Reduction IS Needed in SAH

---

🎯 BP Targets in SAH - Let's Be Precise

⚠️ The Danger Zone:

• Too HIGH → rebleeding risk
• Too LOW → cerebral ischaemia (the injured brain needs perfusion pressure)
• Target: SBP 140-160 mmHg is the sweet spot

---

💊 How Do You Achieve It? Drug Choice Matters!

---

💡 Nimodipine - Don't Forget This One!

This is THE key drug in SAH that you must know:

⚠️ Critical safety point: IV Nimodipine and oral Nimodipine are NOT interchangeable in terms of route/concentration. IV given orally or oral given IV has caused fatal errors. This is a well-documented medication error in SAH management.

---

🔴 Immediate Medication Changes in Mrs. Nadia RIGHT NOW

---

💊 What About Her Seizure & Phenytoin?

---

🎯 Summary - Your Immediate SAH Management Bundle

SAH Confirmed → 
1. Neurosurgical referral (urgent - aneurysm clipping/coiling)
2. IV Labetalol → titrate SBP to 140-160 mmHg
3. Nimodipine 60mg Q4H PO × 21 days (vasospasm prevention)
4. Check Phenytoin level → manage accordingly
5. Strict bed rest, analgesia (paracetamol ± codeine)
6. Avoid NSAIDs (bleeding risk)
7. DVT prophylaxis - mechanical only initially (TED stockings)
8. Stool softeners (avoid Valsalva - raises ICP)

---

• BP reduction need ✅
• Target of 160 mmHg ✅

---

✅ NSAIDs - Correct! Absolutely Avoid

---

💊 Safe Analgesia in SAH

⚠️ Pharmacist pearl: Always prescribe a laxative alongside opioids in SAH. Constipation → straining → Valsalva → raised ICP → rebleeding. This is a simple but life-saving prescription.

---

🫁 Intubation Question - Excellent Clinical Thinking!

---

Does Mrs. Nadia Need Intubation?

• GCS 13/15 - reduced but not critically low
• SpO₂ 96% on air - borderline
• Had one seizure
• Confused

General Rule for Intubation in Neurology:

---

Indications to Intubate in SAH:

---

If Intubation IS Decided - Pharmacist's Role:

---

Post-Intubation Targets in SAH:

---

🎯 Current Status Summary - Mrs. Nadia

Right now:
- No mandatory intubation indication (GCS 13)
- Monitor GCS every 15-30 minutes
- If GCS drops to ≤8 or airway concern → intubate with RSI
- Neurosurgical team to decide timing for angiography/coiling
- Pre-procedure intubation likely needed

Pharmacist actions:
✅ Nimodipine 60mg Q4H started
✅ IV Labetalol titrating to SBP 140-160
✅ Paracetamol 1g QDS for analgesia
✅ Laxative prescribed (lactulose/senna)
✅ Phenytoin level checked
✅ NSAIDs avoided
✅ RSI drugs prepared and checked if intubation needed

---

---

🧠 First - What is Endovascular Coiling?

Normal aneurysm treatment options:
1. Surgical clipping - open brain surgery, metal clip placed on aneurysm neck
2. Endovascular coiling - minimally invasive, done via groin artery

How Coiling Works:

Groin artery (femoral) 
        ↓
Catheter threaded up to brain vessels
        ↓
Platinum coils pushed into aneurysm sac
        ↓
Coils cause clot formation INSIDE aneurysm
        ↓
Aneurysm excluded from circulation → no more bleeding risk

---

💊 Now - The Antiplatelet/Anticoagulation Challenge

---

📋 Anticoagulation During the Procedure (Intra-operative)

---

💊 Post-Procedure Antiplatelet Strategy

Scenario A - Simple Coiling (no stent):

Scenario B - Stent-Assisted Coiling or Flow Diverter:

---

⚠️ The Clinical Dilemma in Mrs. Nadia

She just had SAH (brain bleed)
            +
May need stent-assisted coiling
            +
Already on Nimodipine (which lowers BP)
            ↓
DAPT (Aspirin + Clopidogrel) needed for stent
            ↓
But DAPT increases rebleeding risk in early SAH!

How This is Managed:

---

💡 Nimodipine Interaction with Antiplatelets?

---

🎯 The Pharmacist's Checklist Post-Coiling

After endovascular coiling in SAH:

1. Was a stent used?
   → YES: Start DAPT (Aspirin + Clopidogrel) - liaise with neurosurgeon for timing
   → NO: No routine antiplatelet needed

2. Continue Nimodipine 60mg Q4H × 21 days (vasospasm prevention - non-negotiable)

3. Monitor BP: SBP 140-160 mmHg (pre-aneurysm securing)
   After securing: some centres allow slightly higher BP to prevent vasospasm

4. DVT prophylaxis:
   → Mechanical (TED stockings, pneumatic compression) first
   → LMWH only after aneurysm secured + neurosurgical approval

5. Watch for post-procedure complications:
   → Vasospasm (Days 4-14 post SAH) - most dangerous period
   → Hydrocephalus
   → Hyponatraemia (SIADH or cerebral salt wasting - common in SAH)

---

🔑 Key Teaching Points Summary

---

📋 Case Wrap-Up: Mrs. Nadia, 58F - Subarachnoid Haemorrhage

---

🏥 Final Diagnosis

• Thunderclap headache + vomiting
• Seizure
• Hypertensive emergency
• Reduced GCS

---

💊 Complete Medication Reconciliation

---

🔑 Top 5 Pharmacist Learning Points from This Case

• 60mg every 4 hours for 21 days
• Prevents vasospasm - the biggest killer after initial bleed
• NEVER give oral formulation intravenously - fatal medication error

• Too high = rebleeding
• Too low = cerebral ischaemia
• Use IV titratable agents (Labetalol, Nicardipine)

• Reduces Amlodipine efficacy (CYP3A4)
• Reduces Levothyroxine levels (T4 metabolism accelerated)
• Always check level - narrow therapeutic index (10-20 mg/L)

• Simple coiling = no routine DAPT
• Stent-assisted = Aspirin + Clopidogrel required

• Caused by SIADH or cerebral salt wasting
• Monitor Na⁺ daily
• Two different mechanisms = two different treatments (fluid restrict vs IV saline)

---

📊 Case Performance - Dr. Afzal

---

🎓 Overall

---

---

🏥 Ward Round - Bed 4, Gastroenterology Ward

---

Presenting Complaint

---

Background History

• Chronic liver disease (alcohol-related cirrhosis - Child-Pugh B)
• Type 2 Diabetes
• Osteoarthritis (both knees)
• Heavy alcohol use (approximately 10-12 units/day)
• Smoker (15 cigarettes/day)

---

Current Medications

• Ibuprofen 400mg TDS (self-prescribed, for knee pain)
• Metformin 1g BD
• Spironolactone 100mg OD
• Propranolol 40mg BD

---

Observations on Admission

• BP: 88/54 mmHg (lying)
• HR: 118 bpm (regular)
• SpO₂: 95% on air
• RR: 20/min
• Temp: 37.0°C
• GCS: 15/15 (alert)
• Pallor +++, cold peripheries

---

Over to you Dr. Afzal...

---

✅ Correct - Oesophageal Varices Most Likely

Why Varices in This Patient?

Chronic alcohol use
        ↓
Liver cirrhosis (Child-Pugh B confirmed)
        ↓
Portal hypertension (increased pressure in portal vein)
        ↓
Blood diverts to collateral vessels
        ↓
Oesophageal varices form (thin-walled, high pressure)
        ↓
Rupture → massive haematemesis

Ibuprofen 400mg TDS - self-prescribed!

---

🚨 But First - This Patient is in Haemorrhagic Shock!

Shock Index = HR ÷ SBP = 118 ÷ 88 = 1.34

• Normal <0.8

• 1.0 = significant haemorrhage

• 1.4 = massive haemorrhage, life threatening

---

💊 Immediate Pharmacological Priorities

1. Resuscitation - Fluids & Blood

2. Vasoactive Drug - URGENT

⚠️ Start Terlipressin BEFORE endoscopy - do not wait. Every minute of active variceal bleeding increases mortality.

3. Antibiotic Prophylaxis - Often Forgotten!

4. Airway Protection

---

🔴 Medications to STOP Immediately

---

⚠️ Propranolol - Important Teaching Point

• Propranolol prevents the compensatory tachycardia your body needs
• Worsens hypotension
• Hold it now, restart once stable

---

📋 Summary - First 30 Minutes

Mr. Imran - Variceal Bleed + Haemorrhagic Shock

IMMEDIATE:
✅ 2x large bore IV access
✅ Cautious IV fluids (crystalloid)
✅ Crossmatch 4 units blood
✅ Terlipressin 2mg IV NOW
✅ Ceftriaxone 1g IV NOW
✅ Stop Ibuprofen, Metformin, Propranolol, Spironolactone
✅ Urgent endoscopy (within 12 hours per BSG guidelines)
✅ Involve GI team + ITU

MONITORING:
- BP, HR every 15 minutes
- Urine output (catheterise)
- Hb, coagulation, U&E, LFTs, ammonia

---

---

🧠 What is Happening to Mr. Imran?

He has developed Hepatic Encephalopathy (HE)

---

What is Hepatic Encephalopathy?

Liver cirrhosis → liver cannot detoxify ammonia
                        ↓
Ammonia (NH3) accumulates in blood
                        ↓
Crosses blood-brain barrier
                        ↓
Astrocyte swelling + neurotransmitter disruption
                        ↓
Brain dysfunction → confusion, agitation, coma

Why Did It Happen NOW - After the Bleed?

The GI bleed is the classic precipitant of HE - blood is protein, gut bacteria digest it, produce massive ammonia load.

---

📊 Grading Hepatic Encephalopathy

West Haven Criteria:

---

💊 Pharmacological Management of HE

1. Lactulose - First Line

Lactulose mechanism:
Gut pH lowered by lactulose
        ↓
NH3 + H⁺ → NH4⁺
        ↓
NH4⁺ cannot cross gut wall
        ↓
Excreted in faeces
        ↓
Blood ammonia falls
        ↓
Brain function improves

2. Rifaximin - Second Line / Add-On

3. Treat the Precipitant

---

⚠️ What to AVOID in HE

⚠️ Classic exam trap: Nurses may want to give Lorazepam for his agitation. As the pharmacist you must intervene - NO benzodiazepines in HE.

---

💡 What About His Agitation?

---

💉 Thiamine - Don't Miss This!

Confused alcoholic patient
        ↓
ALWAYS: IV Thiamine FIRST
        ↓
THEN: IV Glucose if hypoglycaemic
        ↓
NEVER: Glucose before Thiamine

---

📋 Full Management Summary for HE in Mr. Imran

Hepatic Encephalopathy - Grade 2

PHARMACOLOGICAL:
✅ Lactulose 30-50ml Q1-2H until bowels open → then titrate to 2-3 stools/day
✅ Rifaximin 550mg BD (add on)
✅ IV Pabrinex (Thiamine) - 2 pairs TDS × 3 days
✅ Continue Ceftriaxone (treat infection precipitant)
✅ Correct electrolytes (K⁺, Na⁺, Mg²⁺)

AVOID:
🔴 Benzodiazepines
🔴 Opioids
🔴 Sedatives
🔴 Glucose before Thiamine

MONITORING:
- GCS/conscious level hourly
- Ammonia level (repeat in 12-24 hours)
- Blood glucose (hypoglycaemia common in cirrhosis)
- Urine output
- If GCS deteriorates → escalate to ITU, consider intubation

---

🔑 Key Learning Points

---

📋 Complete Treatment Summary - Mr. Imran, 45M

Alcoholic Cirrhosis + Variceal Bleed + Hepatic Encephalopathy

---

🔴 Phase 1 - Acute Resuscitation (0-30 minutes)

---

🟠 Phase 2 - Variceal Bleed Management (Immediate)

---

🟡 Phase 3 - Hepatic Encephalopathy Management

---

🔵 Phase 4 - Medication Reconciliation

Stopped/Held:

To Restart Once Stable:

---

🟢 Pain Management for Osteoarthritis (Long Term)

---

⛔ Drugs Contraindicated in This Patient (Permanently)

---

📊 Monitoring Plan

---

🎯 Secondary Prevention - Discharge Planning

---

🔑 Top 5 Pharmacist Pearls from This Case

---

📊 Case Performance - Dr. Afzal

---

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🏥 Ward Round - Bed 9, Respiratory Ward

---

Presenting Complaint

---

Background History

• Bronchial Asthma (diagnosed age 12)
• Allergic Rhinitis
• GORD (gastro-oesophageal reflux disease)
• No smoking history
• No known drug allergies documented

---

Current Medications

• Salbutamol 100mcg inhaler (PRN)
• Beclometasone 200mcg BD (inhaled)
• Montelukast 10mg ON
• Omeprazole 20mg OD
• Ibuprofen 400mg TDS (prescribed by GP 5 days ago for back pain)

---

Observations on Admission

• BP: 118/74 mmHg
• HR: 124 bpm
• SpO₂: 89% on air → 93% on 15L non-rebreather mask
• RR: 32/min
• Temp: 36.9°C
• PEFR: 38% of predicted
• Speech: words only (cannot complete sentences)

---

Over to you Dr. Afzal...

---

✅ Ibuprofen - Excellent Catch!

Why Ibuprofen is Dangerous in Asthma:

Ibuprofen (NSAID) → COX-1 inhibition
                        ↓
Arachidonic acid diverted to lipoxygenase pathway
                        ↓
Excess leukotriene production (LTC4, LTD4, LTE4)
                        ↓
Bronchospasm + airway inflammation
                        ↓
Asthma attack triggered/worsened

---

📊 Asthma Severity Classification - Let Me Teach You This

Classify by the WORST feature present:

Now Apply to Mrs. Zara:

➡️ Mrs. Zara = LIFE-THREATENING ASTHMA 🚨

---

🚨 Additional Life-Threatening Features to Check

⚠️ Critical point: In asthma, a normal CO₂ (4.5-6 kPa) is actually alarming - it means the patient is exhausted and can no longer hyperventilate. Immediate escalation needed.

---

💊 Immediate Pharmacological Management

Step 1 - Oxygen

Step 2 - Bronchodilators (Immediate)

Why add Ipratropium? In life-threatening asthma, combining Salbutamol (β2 agonist) + Ipratropium (anticholinergic) gives greater bronchodilation than either alone. GINA 2025 recommends this combination in severe/life-threatening attacks.

Step 3 - Systemic Corticosteroids (Urgent)

Steroids take 4-6 hours to work - give them NOW, do not delay.

Step 4 - Magnesium Sulphate (Life-Threatening)

---

📋 What About Her Regular Medications?

---

⚠️ Drugs to Avoid in Asthma

---

🎯 Immediate Management Bundle - First 30 Minutes

Mrs. Zara - Life-Threatening Asthma

IMMEDIATE:
✅ High flow O₂ → target SpO₂ 94-98%
✅ Salbutamol 5mg nebulised (O₂-driven) - back to back initially
✅ Ipratropium 0.5mg nebulised - add to Salbutamol
✅ Hydrocortisone 100mg IV QDS (or Prednisolone 50mg oral)
✅ Magnesium Sulphate 2g IV over 20 minutes
✅ STOP Ibuprofen immediately
✅ Inform senior/ITU - life-threatening attack
✅ ABG - check CO₂ level urgently
✅ CXR - rule out pneumothorax

MONITORING:
- SpO₂ continuous
- PEFR every 15-30 minutes (target improvement >50%)
- HR, RR every 15 minutes
- Repeat ABG in 1 hour if not improving

---

🔑 Key Learning Points

---

---

⚠️ Gentle Correction - "Type 1 Asthma"

Let me teach you Respiratory Failure Types - very important here:

Mrs. Zara's ABG (just resulted):

---

✅ Intubation - You Are Right to Escalate!

Indications to Intubate in Asthma:

---

💊 BUT - Before Intubating, Try These First!

• Pneumothorax (high airway pressures)
• Cardiovascular collapse
• Mucus plugging of ETT

Option 1 - IV Salbutamol

Option 2 - IV Aminophylline

Option 3 - Heliox

---

🫁 If Intubation Proceeds - RSI Drug Choice in Asthma

⚠️ Note: Ketamine is PREFERRED in asthma intubation - opposite of SAH where we avoided it! Context determines drug choice.

---

🏥 Post-Intubation Ventilation Strategy in Asthma

Permissive hypercapnia = deliberately allowing CO₂ to rise to avoid barotrauma from high airway pressures. Lower rate + longer expiration = lungs can empty properly.

---

⚠️ Post-Intubation Pharmacology

---

📋 Escalation Summary - Mrs. Zara

Hour 1 - Not improving → Escalate:

STEP 1 (Next 15 minutes):
✅ IV Salbutamol 250mcg bolus → infusion
✅ IV Aminophylline (if not on theophylline)
✅ Call ITU NOW - do not delay
✅ Repeat ABG

STEP 2 (If no improvement / Type 2 RF confirmed):
✅ RSI with Ketamine + Rocuronium + Fentanyl
✅ Avoid Thiopentone, Morphine, Suxamethonium
✅ Post-intubation: permissive hypercapnia strategy
✅ Continue Salbutamol nebs via ventilator
✅ Monitor K⁺ aggressively - replace to >4.0

STOP PERMANENTLY:
🔴 Ibuprofen - document NSAID sensitivity
🔴 Any future NSAIDs or Aspirin

---

🔑 Key Learning Points

---

---

📊 RASS Scale - Full Explanation

---

🎯 What Should Mrs. Zara's RASS Target Be?

Phase 1 - Before Intubation (Right Now):

• Awake, GCS 15
• Distressed, breathless, fighting to breathe
• Speaking in words only

No sedation needed yet - she is not intubated. Agitation is appropriate - it is her respiratory distress driving it.

---

Phase 2 - Immediately Post-Intubation:

---

💊 Sedation Drugs to Achieve Target RASS in Ventilated Asthma

Avoid in Ventilated Asthma:

---

🔄 How RASS is Used Practically - Daily ITU Routine

Every morning on ITU ward round:

1. Check current RASS score
        ↓
2. Is patient at target RASS?
        ↓
3. Daily sedation hold (SAT - Spontaneous Awakening Trial)
   → Reduce/stop sedation
   → Reassess RASS
        ↓
4. If RASS reaches 0 to -1 and stable:
   → Spontaneous Breathing Trial (SBT)
   → Consider extubation
        ↓
5. If patient agitated (+1 or above):
   → Reassess pain first (CPOT score)
   → Retitrate sedation

---

📊 RASS + Delirium Assessment - CAM-ICU

As a clinical pharmacist on ITU, you should be checking RASS + CAM-ICU daily and reviewing sedation appropriateness.

---

🎯 RASS Target Summary for Mrs. Zara

Timeline:

Pre-intubation now:
RASS +1 to +2 (distressed, no sedation needed yet)
        ↓
Immediately post-intubation (first 24-48 hours):
Target RASS -2 to -3
Drugs: Propofol + Ketamine infusion + Fentanyl
        ↓
Bronchospasm improving (Day 2-3):
Target RASS -1 to -2
Reduce sedation slowly
        ↓
Weaning phase:
Target RASS 0 to -1
Daily sedation hold → SBT → extubation if ready

---

🔑 Key Pharmacist Pearls on RASS

---

---

🏥 Ward Round - Bed 3, Endocrine/Medical Ward

---

Presenting Complaint

---

Background History

• Type 1 Diabetes Mellitus (diagnosed age 19)
• Hypertension
• Depression
• Lives alone during weekdays (wife visits weekends)

---

Current Medications

• Insulin Glargine (Lantus) 24 units SC nocte
• Insulin Aspart (NovoRapid) variable dose with meals
• Ramipril 5mg OD
• Sertraline 100mg OD
• Paracetamol 1g QDS PRN

---

Observations on Admission

• BP: 98/62 mmHg (hypotensive)
• HR: 114 bpm
• SpO₂: 97% on air
• RR: 26/min (deep, sighing respirations)
• Temp: 38.2°C
• GCS: 13/15
• Breath: fruity/acetone smell noted by nurse

---

Bedside Results

• Blood glucose: 28.4 mmol/L
• Ketones (blood): 5.8 mmol/L
• Urine dipstick: Ketones +++, Glucose +++, Leucocytes +, Nitrites +

---

Over to you Dr. Afzal...

---

📋 Additional History & Results

Urinary Symptoms:

✅ This confirms a urinary tract infection (UTI) as the likely precipitant of his DKA

---

Urgent Bloods Result:

---

✅ DKA Confirmed - Severity Assessment

DKA Diagnostic Criteria (all three must be present):

Severity:

➡️ Mr. Hassan = SEVERE DKA 🚨

• pH 7.18
• HCO₃ 8 mmol/L
• Ketones 5.8 mmol/L

---

⚠️ Now - The Potassium Problem

Why is K⁺ HIGH in DKA despite total body K⁺ DEPLETION?

Insulin deficiency + acidosis in DKA
        ↓
H⁺ ions move INTO cells
        ↓
K⁺ shifts OUT of cells into bloodstream
        ↓
Serum K⁺ appears HIGH
        ↓
BUT total body potassium is actually DEPLETED
(lost through vomiting + osmotic diuresis)

---

💊 DKA Management Protocol - Step by Step

Step 1 - IV Fluids (Start IMMEDIATELY)

When glucose falls to <14 mmol/L → switch to 10% Dextrose alongside saline to prevent hypoglycaemia while continuing insulin

---

Step 2 - Insulin (CRITICAL TIMING WITH K⁺)

⚠️ Do NOT stop background Glargine (Lantus) - continue 24 units nocte throughout DKA treatment. Common error to stop it!

---

Step 3 - Potassium Replacement (Guided by levels)

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Step 4 - Treat the Precipitant (UTI)

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Step 5 - Medications to Review

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📊 DKA Monitoring - Hourly

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🔑 DKA Key Pearls for Pharmacist

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🩸 Blood Glucose - Converted

Conversion formula: mmol/L × 18 = mg/dL

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🫁 ABG / VBG Values - Converted

Mr. Hassan's Gas Results:

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🌬️ Why is PaCO₂ Low in DKA?

Metabolic acidosis (HCO₃ = 8)
        ↓
Body tries to compensate
        ↓
Increases respiratory rate (RR 26/min)
        ↓
Blows off CO₂
        ↓
PaCO₂ drops to ~25-28 mmHg
        ↓
This is Kussmaul breathing
(deep, sighing respirations noted on admission)

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📊 Full ABG Reference - Normal vs Mr. Hassan

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🔄 Useful Conversion Formulas

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✅ What You Got Right

• Recheck blood glucose ✅
• Consider stopping insulin ✅
• Start KCl infusion ✅

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⚠️ Refinement - The Correct Protocol

K⁺ = 3.1 mmol/L - This is HYPOKALAEMIA

K⁺ drops to 3.1 mmol/L during insulin infusion
                ↓
K⁺ < 3.5 mmol/L threshold reached
                ↓
STOP insulin infusion IMMEDIATELY
                ↓
START urgent KCl replacement
                ↓
Recheck K⁺ after 1 hour
                ↓
Once K⁺ > 3.5 → restart insulin

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💊 Exact KCl Replacement Protocol

KCl Infusion for K⁺ 3.1:

⚠️ Never give KCl as IV bolus - fatal cardiac arrhythmia. Always diluted, always infusion.

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🩸 Why Recheck Glucose Too - Good Point!

At Hour 3 - Expected Glucose:

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📋 Complete Decision Tree - Hour 3 Actions

Hour 3 results:
K⁺ = 3.1 mmol/L → STOP insulin NOW
                 → Start KCl 40mmol in 1L NaCl over 1 hour
                 → ECG monitoring

Recheck glucose:
→ If glucose >14 mmol/L (>252): continue saline, restart insulin once K⁺ >3.5
→ If glucose <14 mmol/L (<252): add 10% dextrose 125ml/hr alongside saline
→ If glucose <4 mmol/L (<72): treat hypoglycaemia - 150ml 10% dextrose bolus

After 1 hour - recheck K⁺:
→ K⁺ >3.5 → restart insulin infusion 0.1 units/kg/hr
→ K⁺ still <3.5 → continue KCl, do not restart insulin yet
→ K⁺ <2.5 → emergency, escalate to senior immediately

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⚠️ ECG Changes to Watch With K⁺ 3.1

Pharmacist role: Flag K⁺ to nurse and doctor immediately, ensure cardiac monitoring is on, ensure KCl is prescribed correctly (right concentration, right rate).

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🔑 The Golden Rules of K⁺ in DKA

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📋 SOAP Note - Mr. Hassan, 52M

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S - SUBJECTIVE

• Type 1 Diabetes Mellitus (33 years)
• Hypertension
• Depression

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O - OBJECTIVE

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A - ASSESSMENT

Primary Problem:

Pathophysiology Summary:

Insulin deficiency + infection (counter-regulatory hormones)
                ↓
Uncontrolled lipolysis → ketone production
Uncontrolled gluconeogenesis → hyperglycaemia
                ↓
Osmotic diuresis → dehydration → AKI
Ketone accumulation → metabolic acidosis
K⁺ shifts extracellularly → apparent hyperkalaemia
                ↓
Severe DKA: pH 7.18, HCO₃ 8, ketones 5.8

Drug-Related Problems Identified:

Complications Identified:

• Acute Kidney Injury (creatinine 168, eGFR 42)
• Hyperkalaemia on admission (K⁺ 6.1) - transcellular shift
• Hypokalaemia risk once insulin commenced
• Urinary Tract Infection (precipitant)
• Hyponatraemia (Na⁺ 131 - dilutional)

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P - PLAN

1. Fluid Resuscitation

2. Insulin Management

• Glucose fall: 3-4 mmol/L (54-72 mg/dL) per hour
• Ketone fall: 0.5 mmol/L per hour
• Continue FRIII until: ketones <0.3 + pH >7.3 + eating

3. Potassium Management

• Never give as IV bolus - always diluted infusion
• Maximum peripheral rate: 20mmol/hour
• Continuous ECG monitoring during replacement
• Recheck K⁺ every hour
• Restart insulin only when K⁺ >3.5

4. Antibiotic Therapy (UTI Precipitant)

5. Medication Reconciliation

6. Monitoring Plan

7. DKA Resolution Criteria (Before stopping FRIII)

• ✅ Blood ketones <0.3 mmol/L
• ✅ pH >7.3
• ✅ Patient eating and drinking

8. Patient Counselling at Discharge

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📊 Case Performance - Dr. Afzal

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🏥 Ward Round - Bed 6, Cardiology Ward

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Presenting Complaint

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Background History

• Hypertension (10 years)
• Type 2 Diabetes Mellitus
• Hypercholesterolaemia
• CKD Stage 2 (baseline creatinine ~115 µmol/L)
• Gout (one episode 2 years ago)
• Ex-smoker (stopped 5 years ago, 30 pack-year history)

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Current Medications

• Amlodipine 10mg OD
• Losartan 50mg OD
• Metformin 1g BD
• Atorvastatin 20mg ON
• Allopurinol 100mg OD
• Aspirin 75mg OD (started 1 year ago by GP)

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Observations on Admission

• BP: 156/94 mmHg (right arm) / 154/92 mmHg (left arm)
• HR: 96 bpm (regular)
• SpO₂: 94% on air
• RR: 20/min
• Temp: 36.8°C
• GCS: 15/15 (alert, distressed)
• Diaphoretic, pale, clutching chest

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ECG on Admission

"ST elevation of 3mm in leads II, III, aVF. Reciprocal ST depression in leads I and aVL. Normal sinus rhythm. No bundle branch block."

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Over to you Dr. Afzal...

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🎯 Refocusing - Clinical Pharmacist Role on Ward Rounds

• Diagnose conditions
• Interpret ECGs
• Make medical management decisions

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✅ What a Clinical Pharmacist ACTUALLY Does on Ward Rounds

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🏥 Let's Redo This Case - Pharmacist Perspective

• Diagnosed Inferior STEMI
• Ordered primary PCI
• Asked for your input as clinical pharmacist

The Physician Asks You:

"Dr. Afzal, the diagnosis is Inferior STEMI. We are activating the cath lab for primary PCI. Can you please review his medications and advise on the pharmacological management from your end?"

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Now This Is YOUR Territory - Drug Chart Review:

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✅ Your Recommendations - Feedback

1. Aspirin 300mg loading dose ✅ Correct!

2. Clopidogrel 300mg ✅ Correct - but let's refine!

Current ESC 2023 STEMI guidelines prefer Ticagrelor over Clopidogrel for STEMI going to PCI - stronger, faster antiplatelet effect. Clopidogrel is acceptable but second choice unless Ticagrelor contraindicated.

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📋 Labs You Requested - Here They Are:

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1. What is your decision on Metformin?
2. What is your decision on Atorvastatin 20mg given his LDL and this is a STEMI? 🎯

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✅ Point 1 - Metformin - CORRECT, Stop It!

Metformin Stopping Rules - Teach Yourself:

What to Use Instead for Diabetes in Acute MI?

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⚠️ Point 2 - Statin Switch - Good Thinking but Let Me Refine!

Why Did You Want to Switch?

Key point: Atorvastatin is actually SAFER in CKD than Rosuvastatin because it has virtually no renal clearance. The concern about creatinine does not limit Atorvastatin dose escalation.

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The Real Reason to Escalate Statin in STEMI:

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Your Switch to Rosuvastatin 20mg - Is It Right?

Conclusion: Your clinical decision to escalate to high intensity statin is correct. However the reasoning needs refinement - switch to Rosuvastatin is acceptable, but you could equally have just escalated Atorvastatin to 40-80mg which is actually more renal-friendly.

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Rosuvastatin in CKD - Important Dose Cap:

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📋 Updated Drug Chart - Mr. Khalid Post-Pharmacist Review

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🔑 Key Pharmacist Pearls - STEMI Drug Review

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