Dad Back in the Hospital Again

Oh My.
My suggestion at this point would be to get a notebook and write down everything you have questions about.
Some things I would want to know are..

1) Why is dad on Vanco? What is the diagnosis?

2) A list of all the drugs they have been giving him. Take this list to your local pharmacy and ask the pharmacist to review them with you. Ask for a printed page of the drug...The data bases they use at the pharmacy will also flag any possible interactions with other drugs.
Having this printed material can help educate you when the docs start throwing medication names around and you will have them to refer to.

3) If the blood pressure machine is unable to record a BP of 190/80 (which I have never heard of) request that they take his BP the "old fashioned way". The thought of an uncalibrated or faulty BP machine should be reported and I would make sure that it is.

4) How soon can I get my dad transferred out of here and to a hospital where his doc has privledges? Make phone calls as soon as tomorrow to get that ball rolling. Does his regular Uro answer his own call? If so he would be a great person to start with.

5) I would watch the fluid restriction chart like a hawk. Make sure everyone is charting correctly and is aware of any outside fluids he is getting (gatorade). I have seen some sloppy In/Out charting done. If it is not accurately done the use of certain medications is useless. Remember 1 ounce = 30 CC's. Make sure everyone is using the same standard of measurement.

I could go on and on but those are the most important things I would focus on. This of course is just my opinion. I have been an active patient advocate for my husband and also have worked with families to help them be the best advocate they can be.

Good luck!

Wow! What great info even though it scares the crap out of me since none of that is being done or taken into account in my Dad's case. The ID has been to see him ONE time in the week he has been here. In the meantime, they have him on one gram of the vanco daily. They seem to always draw the blood shortly after the vanco has been given which, in my opinion, skews the results. Seems to me the blood draw should be about 30 minutes before his next dose. I'm for firing the current ID and finding someone who is willing to be more on top of things. This is serious stuff that requires more than a one time visit and the same dosage all the time.

The nuclear kidney scan to check for renal artery blockage came back "inconclusive" which we were told occurs about 20% of the time. The kidney doctor who is trying to get the BP adjusted left town for the weekend (of course!) so nothing is going to change regarding the 7 blood pressure meds he is being given twice a day that haven't lowered the pressure at all! This morning it was 190/80. It has been so high that the little machine they wheel in to take the BP is not able to take it! The kidney guy said there were only 2 more BP meds known to man and if Dad's pressure did not come down soon, he would add those to the mix!

The kidney doc increased the lasix to 40mg 3x daily. Not a big deal since Dad can hook up to a big night bag but the lasix also damages the kidneys by making them work harder not to mention washing out the sodium and potassium. Dad is currently on fluid restriction but even with that and the lasix, his hands, feet, ankles, abdomen and face are still greatly swollen. Not sure what it is going to take to get the fluids out of him. He is hardly drinking anything, which I keep telling him is not the thing to do. I brought him some Gatorade to drink (with the neph's permission.) My fear is that he will become dehydrated on top of everything else.

The internist is a "hospitalist" and has been Dad's doctor for almost a week now. Imagine my surprise when I asked him about the blood in Dad's urine and he tells me that "it's not unusual to see blood with a Foley catheter."!! He didn't even know Dad had a urostomy! The guy taking his call today also said the blood was due to a Foley and when I told him that was impossible because there was no Foley and that Dad has a urostomy, he said "Is that the thing that comes out the back?"!! This is an internist practicing in a big city hospital!! Plus, there are so few American doctors here, it is difficult to understand anything any of them (or the nurses) say.

We're having a little controversy about flushing Dad's Picc line. The policy at this hospital seems to be not to flush with heparin. Home health care taught him to flush with saline first and heparin at the end. One "nurse" tried to get away with flushing the line with IV saline when Dad is on fluid restriction. I had to go to the charge nurse about that one. None of the "nurses" flush before using a line and some don't flush the line after using it. It is SOOO frustrating. If you ask them to clean their hands before touching you, they get mad. Please, Dad already has an infection. We don't need another.

Dad developed a pain in the area of his Achilles tendon and it became severe and started moving up his leg. The on-call ordered a scan to check for a clot. No clot, so it is most likely tendonitis. He now has yet another pill to take for inflammation!

It's the strangest thing. At times Dad's urine is the color of raspberry tea. Then the foley bag is emptied and the next urine that comes out is the pale yellow color of straw. He has received IV iron 3 times now and the magnesium was dark or maybe it was the potassium. There have been so many drugs it is hard to keep them straight! He even got a shot of Procrit today even though they are giving him a blood thinner shot in the stomach twice a day. Not sure what that's all about.

This whole experience brings back so many bad memories of impossible-to- reach doctors and uncaring, lazy nurses and techs who never come when you call. There has been one really competent nurse here so far who was a joy to have take care of you. Unfortunately, we changed floors and I have yet to find such a nurse on this floor. Too bad. To some, it is just a job.

I think there is still yeast in his urine. After a lot of days on Diflucan, maybe they need to try a different yeast drug. Call me crazy. We need to get out of here and into a place where Dad's regular docs have privileges. The internist today said he was going to have to bring in a urologist because of blood in the urine. Great! That will be uro #4!

Pat you are always such a wealth of information it's amazing. Do you think harleygirl's dad has Methicillin-resistant Staphylococcus Epidermidis (MRSE)?

If so I would think the ID doc should have said that. But then again if the doc only works two days a week it wouldn't suprise me if she didn't.

We were very lucky to have the most dedicated ID doctor ever. Probably the most dedicated doctor period. He stayed on top of my husband's treatments daily. He always popped into the infusion center even on Saturday and Sunday mornings to keep an eye on everything.

Pat you also have refreshed my memory of the importantce of the speed of which the Vanco had to administered. I know it was 4 hours a day and it set as so for a reason.

Harley here is some info and I hope it helps.

Monitoring parameters
Careful observation for signs of drug toxicity is imperative.

The following patient parameters should be monitored during vancomycin therapy:
Vancomycin peak and trough levels
Obtain at steady-state (approximately four half lives) and then weekly during therapy.
BUN and serum creatinine
Measure every two days, or every day in unstable renal function.
Weight
Weigh patient every two to seven days.
Urine output
Measure and monitor urine output daily.
Baseline and weekly audiograms.
Check for signs of phlebitis daily.

www.rxkinetics.com/pktutorial/2_5.html

I suggest the ID doc me more involved and if she can't commit to doing so I would be looking for someone who could.

Let us know how the tests they are running come back. I'm intertesed in knowing.

Pamela

Harley....sounds like physician russian roulette to me.
Vancomycin is resistant to staph epidermis and yeast.
Also dosage in the older patient needs to be reduced especially if there is renal involment but they haven't checked that?? It also has to be administered very slowly over 60 mins.
Patients with Impaired Renal Function and Elderly Patients

Dosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of Vancomycin serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function. Vancomycin serum concentrations can be determined by use of microbiologic assay, radioimmunoassay, fluorescence polarization immunoassay, fluorescence immunoassay, or high-pressure liquid chromatography.

If creatinine clearance can be measured or estimated accurately, the dosage for most patients with renal impairment can be calculated using the following table. The dosage of Vancomycin hydrochloride per day in mg is about 15 times the glomerular filtration rate in mL/min:

DOSAGE TABLE FOR Vancomycin

IN PATIENTS WITH IMPAIRED RENAL FUNCTION

(Adapted from Moellering et al)4

Creatinine Clearance
Vancomycin Dose

mL/min
mg/24 h

100
1545

90
1390

80
1235

70
1080

60
925

50
770

40
620

30
465

20
310

10
155


The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

see this article on staph epidermis and yeast.
jmm.sgmjournals.org/cgi/content/short/51/4/344

I just don't know what to say...to even send your father home and expect your mother to administer Vancomycin ?? What is that?
Pat

Thanks for the replies.

The infectious disease doc says it is not MRSA but that it is staph epidermis and yeast. I'm not sure what the difference is between MRSA and staph epidermis since MRSA is on the epidermis, but what do I know?

Dad was administering the vanco along with Zosyn to himself after Home Health Care showed him how. They were checking the trough and found last Sunday that the vanco levels were way too high. In the hospital, they seem to take random draws to check the troughs and the level is still showing to be too high. They can not reach the infectious disease doctor as she only works 2 days a week (??!) so he has not had any vancomycin for two days now in the hospital.

His blood pressure is elevated and they currently have him on 6 drugs to try to bring it down. Yep, that's SIX! He had a nuclear stress test and echocardiogram, both of which were normal. So it is not the heart causing the chest pain. The next place to look is the kidneys and he is having a nuclear scan with doppler there tomorrow morning to determine if perhaps the renal arteries are blocked. If that is the case, he will need stents.

I think the doctors are just throwing stuff up against the wall to see what sticks when it comes to giving meds. It is amazing how much they DON'T know about the human body! His IV pole looks like a clothesline with Monday's wash hung on it. There are so many bags: potassium, magnesium, iron, antiobiotics, diflucan, blood (2 units) to name a few. He gets a shot in the belly each day with a blood thinner and more pills to take by mouth than you can count.

He is sick of being in the hospital and sick of being ignored by nurses and techs when he rings the call button. That "someone" who they say will be there "shortly" usually never shows up. There are no private rooms in this hospital and the roommate thing is a whole new experience for us.

Not sure where they are going to look if the kidneys don't prove helpful in diagnosis. They are running out of body parts to test!

A month on Vancomycin is not unheard of. My husband had 6 weeks of IV Vanco 4 hours a day 7 days a week. He went to the hospitals infusion center everyday. They should be keeping an eye on his trough levels and this should be done at least once a week.
Am I correct to assume that his infection is a Methicillin resistant infection?

Take Care
Pamela