Monday Morning Patient Care Thoughts

Posted by gulseth.michael on March 13, 2017 at 11:50 AM


While waiting for a doctor to call back so I can stop an un-needed heparin drip, I felt like writing a few miscellaneous thoughts on my mind:


1. We had another rivaroxaban to heparin transition yesterday. In this case, patient had acute PE and went into AKI while on rivaroxaban. 36 hours after a last dose of rivaroxaban, they drew a rivaroxaban level. It was 201 ng/ml, likely at a therapeutic level. Patient had a chest tube placed at that time (the reason rivaroxaban was held), and the question came to me if we wait to start a heparin drip. (We no longer felt rivaroxaban appropriate with AKI.) My answer was, yes, in this case probably better to error on the side of potential over anticoagulation. However, this is a case you have to use aptt to monitor heparin, so we customized a scale and are using that for now. I will wait two days, then maybe check an Xa level to see if in range or low. If it is, we can probably switch back to it at that time since our aptt goals have not been formally correlated to anti-Xa levels as they should be. See my previous blog if you are not aware of these transition issues.


2. A rookie mistake I often see in dosing warfarin for inpatients is a lack of appreciation for how much continuous tube feedings can increase warfarin needs. Don't be shy; get that dose increased!


3. I am convinced one of the biggest benefits our inpatient anticoagulation service provides is creating smooth transitions of care. It is worth the time we spend making sure all critical issues are addressed, and educating patients.


4. My life was simpler when we did not need to use Bactrim to treat MRSA.


5. Will winter ever end? This is starting to feel like a Game of Thrones kind of winter.



Michael P Gulseth, Pharm. D., BCPS, FASHP

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