ICU Stories: Middle-aged patient w multiple co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/atrial fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/ hypotension. Urine was purulent. CT showed hydronephrosis & bladder wall thickening: - ThreadSky

imcrit.bsky.social • 100 days ago

ICU Stories:

Middle-aged patient w multiple co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/atrial fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/ hypotension. Urine was purulent. CT showed hydronephrosis & bladder wall thickening:

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imcrit.bsky.social•100 days ago

Patient received "sepsis fluid bolus" & antibiotics (meropenem and vanco); admitted to the hospitalists' service. Urine & blood cultures grew E .coli. A day later, pt was transferred to the ICU with altered mental status & oral bleeding secondary to tongue biting after a seizure

imcrit.bsky.social•100 days ago

Review of admission labs: WBC 15k, Hb 10.6, PLT 120k, bun/creat 100/3.0 (baseline 15/10.7)
Home meds: apixaban / aspirin / divalproex sodium / escitalopram / folic acid / insulin / hydrochlorothiazide / empagliflozin / statin / clopidogrel / quetiapine
Stat CT brain: old strokes - "nothing acute"

imcrit.bsky.social•100 days ago

What do you think that happened? Any additional imaging (repeat CT / MRI)? Any fancy labs? Were seizures due to the use of meropenem in the setting of renal dysfunction?

imcrit.bsky.social•100 days ago

The valproic acid level was checked and found to be below the level of detection 👇. Was it poor absorption? On admission, valproic (V) had been changed from po to iv (500 mg tid). So what happened?

imcrit.bsky.social•100 days ago

This is actually a quite common scenario (I see it a couple of times per year): the combination of valproate with carbapenems is associated with a potential drug interaction that ⬇️ serum concentration of valproate & exposes the patient to uncontrolled seizures from sub-therapeutic V levels... 😬

imcrit.bsky.social•100 days ago

The therapeutic range of plasma V for seizures is 50-100 mcg/ml; when combined with carbapenems, plasma V concentration is sub-therapeutic in MOST patients. Renal disease & enzyme-inducing AEDs (eg, phenytoin) are risk factors to the reduced V levels during concomitant treatment with carbapenems

drlizgeriatrics.bsky.social•99 days ago

Antipsychotic or anti-depressant SSRI. Decreased seizure threshold.

axel-ellrodt.bsky.social•100 days ago

BTW, what was the rationale for choosing vancomycine / meropenem in this patient ?

imcrit.bsky.social•100 days ago

Multiple MDR UTIs - pcn allergy

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