Inpatient Pocket Card Set

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Satya Patel, MD, Kelley Chuang, MD, Jennifer Fulcher, MD,

PhD, Simon Wu, MD, Tyler Larsen, MD, Michael Spiker, MD,
Michael F. Ayoub, MD, Sean McCarthy, MD, Estelle Everett,
MD, Pamela Tsing, MD, Ashley Saito, MD, Antonio
Pessegueiro, MD

Pre-Rounding Guide
Overnight
Night float signout, nursing notes
Events
Interdisciplinary
Review original note and any addendum
Notes
Vital Signs Trends and ranges (min and max) values
Input: Oral, IV, via feeding tube
I/O and
Output: Urine, stool, drains, ostomy, hemodialysis
Weights Weight trends
Include trends
Labs Review pending/send-out labs
Consider which ones are truly needed on daily basis
Review images yourself
Radiology Note if interpretation is preliminary or final
Bacterial culture not considered “negative” until at least 48
Microbiology hours (does not finalize until day 5)
Pathology Review initial stains and pending stains
IV fluids and drips
Missed doses of medications (and reason for missed doses)
Review medications that have expired/“fallen off”
Review medications that need to be discontinued
Medication
Administration Overnight medications that were written by night float
Record (MAR) Pain medications
Insulin requirements (and glucose ranges)
Antibiotics received and start/end dates
Review if held/modified home meds can be restarted/returned
back to home dose
Cardiac Review telemetry
Monitoring/Pulse Consider if cardiac monitoring and/or pulse oximetry needs to
Oximetry be continued
Review dates of when these were placed
Tubes, Lines,
Review indications for removal and/or replacement on daily
Drains basis
 Daily Checklist
IV fluids (put end-time/total amount and review daily)
Indications for NPO
o Upcoming procedure
o PET scan (also avoid dextrose-containing IV fluids –
FEN/GI
review all IV meds)
o Concern for aspiration of all PO intake (including
medications)
o Avoid caffeine prior to regadenoson stress testinga
o SCDs
o Enoxaparin subQ if CrCl >30 (hold 24 hours before
most procedures)
DVT
o Heparin subQ if CrCl <30 (hold 6 hours before most
prophylaxisb
procedures)
o Contraindications: active bleeding, low platelet count,
upcoming procedures
Indications (for critically ill patients)
o On mechanical ventilator for >48 hours
Stress ulcer
o Coagulopathy (INR >1.5, plt <50)
prophylaxisc
o High-dose/chronic steroid or NSAID use
o Recent GI bleed
Code Options include: Full, DNR/never intubate, DNR/okay to
statusd intubate, compressions okay/never intubate

Disposition Checklist
o Update family/DPOA on status of patient
o Fill out/update POLST form (if indicated)
o Post-hospitalization living situation
o Insurance for meds (prior authorization) and nursing homes
o Post-discharge transportation
o Equipment at home for safety/function
o Outpatient referrals and appointments
o Consider need for prescriptions (new medications, refills)
o Discharge medication education
o Discharge summary (include pending inpatient labs that require
outpatient follow-up)
o Outpatient labs (if needed) and identify provider responsible for results
o Handoff communication to accepting provider (PCP, SNFist, etc.)
a. Some centers require patients to be NPO prior to stress test simply due to policy
b. The FDA has approved some DOACs and fondaparinux as options as well
c. If a patient is on long-standing PPI or H2-blocker therapy which cannot be
discontinued due to symptoms or specific medical indication, this will suffice as
stress ulcer prophylaxis. Consider de-prescribing if no indication
d. At the VA, patients cannot legally have mixed code status (patients must be Full
Code or DNR/never intubate)
 Anti-Emetic Regimen Guide
Class Medication Route Common Side Effects QT-Prolongation
Ondansetron PO, IVP, IM,
✓
Serotonin (Zofran) sublingual
Headache, constipation, drowsiness, diarrhea
antagonists Granisetron (Kytril, PO, IV,
✓
Sancuso) transdermal
Metoclopramide Drowsiness, EPS, do not use if increased GI
PO, IVP, IM ✓
(Reglan) motility
Olanzapine PO, IM,
EPS, hyperglycemia ✓
(Zyprexa) sublingual
Dopamine (DA) Prochlorperazine
PO, IVP, PR EPS, NMS ✓
antagonists (Compazine)
EPS, constipation, dry mouth, blurred vision,
Haloperidol (Haldol) PO, IM ✓
somnolence
Chlorpromazine
IM, IV EPS, dry mouth ✓
(Thorazine)
Histamine Diphenhydramine PO, IVPB,
Dizziness, drowsiness, paradoxical excitation ✓
antagonists (Benadryl) IVP
PO, IVP, IM, Bradycardia, flushing, thirst, xerostomia,
ACh antagonists Scopolamine ✓
transdermal urinary retention
DA/Histamine/ACh Promethazine PO, PR, EPS, NMS, drowsiness, sedation, leukopenia,
✓
antagonist (Phenergan) IVP, IM thrombocytopenia
Neurokinin-1(NK-1) Aprepitant (Emend) PO Hiccups, bradycardia, neutropenia
receptor Fosaprepitant
IV Angioedema, bradycardia, neutropenia
antagonists (Ivemend)
Leukocytosis, mood changes, adrenal
Dexamethasone PO, IVP, IM
suppression, hyperglycemia
Trimethobenzamide
Centrally acting PO, IM EPS, disorientation, seizure
(Tigan)
THC, dronabinol PO Hyperemesis, tachycardia, nystagmus, ataxia
Lorazepam (Ativan) PO, IVP, IM Respiratory depression

When using multiple agents, avoid choosing from the same class
 Bowel Regimen Guide
Class (Mechanism) Medication Side Effects
Polyethylene glycol Nausea, bloating, cramping
Lactulose Abdominal bloating,
Osmotic agents (draws water into Sorbitol flatulence
bowel, thereby loosening stool
and promoting evacuation) Glycerin Rectal irritation
Magnesium sulfate PO
Watery stools and urgency
Magnesium citrate
Bisacodyl Rectal irritation
Stimulant laxatives
Senna Melanosis coli
Bulk-forming laxatives (fiber Impaction above strictures,
absorbs excess water and Psyllium fluid overload, gas, and
stimulates elimination) bloating
Tap water enema
Rectal distension Discomfort during procedure
Fleet enema*

Avoid docusate as it does not help with constipation in hospitalized patientsa

*Fleet enemas contain phosphate and should be avoided in renal insufficiency

a. Robert J Fakheri, MD, Frank M Volpicelli, MD, Things We Do for No Reason: Prescribing Docusate for
Constipation in Hospitalized Adults. J. Hosp. Med 2019;2;110-113. doi:10.12788/jhm.3124
 Pharmacologic Pain Management Options
Class Options
Acetaminophen (24 hours: <3-4g in healthy adults, <3g in CKD, <2g in liver disease or cirrhosis)
Anti-inflammatory Oral NSAIDs or IV ketorolac (avoid NSAIDs if CKD or >2 of the following risk factors: history of GI ulcer,
age >60, on steroids, on ASA/anticoagulation)
Opioid Hydrocodone, morphine, oxycodone, hydromorphone, fentanyl, tramadol, codeine
Topical Lidocaine patch, menthol cream, lidocaine/prilocaine cream, capsaicin cream
Neuropathic
Gabapentin, pregabalin, SNRIs, TCAs
agents
Anti-spasmodic Baclofen, cyclobenzaprine, tizanidine

Opioid Conversion Tablea,b,c

Equianalgesic dosing (mg)
Opioid IV, SC, IM PO Onset Peak t1/2 Considerations
McPherson CDC McPherson CDC
IV: 5-10m IV: 15m Avoid in renal failure, active
Morphine 10 10 25 30 2-4h
PO: 30m PO: 60m metabolites
IV: 5m IV: 10-20m Reduce dosing in hepatic
Hydromorphone 2 1.5 5 7.5 2-3h
PO: 30m PO: 60m dysfunction
Oxycodone N/A N/A 20 20 10-30m 1-2h 3-4h Caution in hepatic dysfunction
Hydrocodone N/A N/A 25 30 10-30m 1-2h 4h Caution in hepatic dysfunction
Preferred for hepatic/renal
Fentanyl 0.15 0.1 n/a N/A 1.5m IV: 5-10min 2h
failure
Risk for serotonin syndrome
Tramadol N/A N/A 120 -- 1h 2h 6-8h
Can ↓ seizure threshold
Prodrug metabolized to
Codeine N/A N/A 200 200 30m-1h 1-1.5h 3h morphine in liver, variable
metabolism

a. Different tables will reference different values – choose one and stick with it. Some hospitals utilize McPherson (Demystifying Opioid Conversion
Calculations: A Guide for Effective Dosing, 2nd Edition by Dr. Mary Lynn McPherson PharmD, BCPS, CPE), while others utilize CDC guidance
b. When rotating opioids, consider reducing equivalent dose by 25-50% to account for incomplete cross tolerance
c.If patients with renal failure, consider fentanyl, methadone or hydromorphone. Avoid morphine due to renally cleared metabolites
 Inpatient Blood Pressure Management Guide
Route Frequently Used Effect
Class Relative/Absolute Contraindications
PO IV Agents on ICP
Metoprolol, Bradycardia, heart block, ADHF, COPD
β-blockers ✓ ✓ ↔
Carvedilol, Labetalol exacerbation
Captopril,
Enalaprilat (IV),
ACEI/ARBs ✓ ✓ AKI, hyperkalemia, angioedema ↔
Lisinopril,
Valsartan
α2 agonistsa ✓ ✓ Clonidine Severe bradycardia ↔
Nitratesa ✓ ✓ Isosorbide dinitrate Severe AS, PDE inhibitor use ↑
Nifedipine ER, HFrEF
CCBsb ✓ ✓ Diltiazem, For non-dihydropyridines: Bradycardia, ↔
Amlodipine heart block
Chlorthalidone,
AKI, hypovolemia, difficulty with
Diuretics ✓ ✓ Hydrochlorothiazide, ↓
transferring to urinate
Spironolactone
Vasodilators ✓ ✓ Hydralazine ↑
Can develop severe reflex tachycardia
Non-selective due to the unpredictable drop in SBP
✓ Phentolamine ↓
α blockers
Partial D1
✓ Fenoldopam Glaucoma ↑
agonists
c
Avoid acute treatment of hypertensive urgency (now known as asymptomatic severe hypertension)
a. Transdermal formulation is available
b. Amlodipine takes approximately 30 hours to become effective
c. Breu AC, Axon RN, Acute Treatment of Hypertensive Urgency. J. Hosp. Med 2018;12;860-862. Published online first October 31, 2018. doi:10.12788/jhm.3086
 IV Fluid Timeouta
Step 1: Indication Step: 2 Approach Step 3: Type of fluidb Step 4: Amount of fluid
Colloids are not superior to crystalloids
Give IV fluids (in 250-1000 mL
LR and Plasma-Lyte can be given in
Low preload state increments) and re-assess volume
hyperkalemia
leading to vital sign status
Resuscitation You cannot rely on serum lactate levels if
changes +/- In sepsis, consider 20-30 mL/kg (use
you give LR to a patient with cirrhosis
symptoms extra caution with heart failure, renal
If increased ICP, consider using Plasma-
failure and cirrhosis)
Lyte instead of LR
Disrupted oral intake Maintenance 0.45% NS with 5% dextrose Calculate amount using “4-2-1” rule
Electrolyte Repletion Guide
Electrolyte Amount Route Details
Potassium !"#$ & ' ()*+#$ &
x 100 = mEq of KCl Oral, IV (10 mEq/hr peripherally, >4 if acute MI, cardiac conditions
(ref range 3.5-4.5) ,-.#*/0/0. ! 20 mEq/hr centrally) KCl >4.5 if VT
!"#$ 12 ' ()*+#$ 12
x 10 = gm of Oral (MgO causes diarrhea, Mg-
Magnesium ,-.#*/0/0. !
>2 if CAD or active cardiac conditions
protein complex does not cause
(ref range 1.3-1.7)
MgSO4 >2.5 for VT
diarrhea), IV MgSO4
Calcium No need to replete unless symptomatic or
1 gm at a time IV calcium carbonate
(ref range 8-10) if QT prolongation
Phosphate See table below Oral, IV Pay attention to K load
(ref range 2.5-4.5)

Phosphate Repletion Guided

Dose (based on phosphate level)
Route Formulation Amount of K
Phos <1.5 Phos 1.5-1.9 Phos 2-2.5
Neutra-Phos 2 packets 1-2 packets 1 packet 7.1 mEq per packet
Neutra-Phos-K 2 packets 1-2 packets 1 packet 14.3 mEq per packet
Oral
2 tablets q4h x4 2 tablets q4h x3 2 tablets q4h x2
K-Phos Neutral (Na and K Phos) 1.1 mEq per tablet
doses doses doses
Potassium Phosphate 18-21 mmol 12-15 mmol 9-12 mmol 4.4 mEq per 3 mmol phos
IV
Sodium phosphate 18-21 mmol 12-15 mmol 9-12 mmol 0 mEq
a. Consider aggressive IV fluids for nephroprotection in specific situations (e.g., tumor lysis, hypercalcemia, etc.)
b. For a table on options for considerations for crystalloids, go to bit.ly/crystalloids (case-sensitive)
c. If creatinine is <1, just divide by 1
d. If CrCl <30, divide dose by 50%
Antibiotic Spectrum (Jennifer Fulcher, MD, PhD, UCLA Infectious Diseases)
Last updated February 24th, 2021

Antimicrobial Stewardship
 Type 2 Diabetes Mellitus Inpatient Medication Guidea Inpatient blood
If NPO, ↑ risk of glucose goal
Class Examples When to hold? 140 – 180 mg/dLb
hypoglycemia?
Lactic acidosis
Biguanide Metformin ↑ risk of developing AKI No Insulin Pearls
GFR <30
↓ or variable oral intake Calculate total daily dose of
Sulfonylurea Glipizide Yes insulin and adjust
GFR <30
Pioglitazone Risk of heart failure or MI appropriately
TZD No
Rosiglitazone ALT >2.5x ULN Weight-based insulin
DPP-4 Alogliptin Prior or current pancreatitis 0.3-0.6 units/kg/day
No
inhibitor Saxagliptin Avoid saxagliptin in heart failure ~50% basal + ~50% mealtime
GLP-1 Dulaglutide Prior or current pancreatitis
receptor Liraglutide Nausea and/or vomiting No If NPO, stop mealtime insulin
agonist Semaglutide Ileus or gastric dysmotility and reduce basal insulin by
~20%
Hold for 72 hours pre-operatively
Empagliflozin Never completely discontinue
SGLT2i ↓ or variable oral intake No*
Dapagliflozin basal insulin in Type 1
Hypovolemia
Diabetes Mellitus
Meglitinide Repaglinide NPO Yes
Cirrhosis Assess for presence of insulin
α-glucosidase Acarbose
Partial bowel obstruction No pumps and continuous
inhibitor Miglitol
Cr >2 glucose monitors in Type 1
Diabetes Mellitus
*Increased risk of euglycemic DKA
If sliding scale insulin
requirements are minimal,
a. “Oral Diabetes Medications Inpatient: Mind the Gap Series.” coreimpodcast.com. Patel, S., Trivedi, S.,
consider discontinuing it
Umpierrez, G., Troy, A., Larsen, T. October 13, 2021. https://www.coreimpodcast.com/2021/10/13/oral-
completely
diabetes-medications-in-hospitalization-mind-the-gap-segment/
b. Nice-Sugar Study Investigators. "Intensive versus conventional glucose control in critically ill Adjust insulin dose for renal
patients." New England Journal of Medicine 360.13 (2009): 1283-1297. dysfunction and older age
 Admission
Setting Details Minimum functional status
requires
On mechanical ventilation, pressors, q1-2h
Intensive Care Unit (ICU)
checks/interventions
Intermediate Care/Step-Down Unit/
On NIPPV, continuous drips
Progressive Care Unit (PCU)
Long-Term Acute Care (LTAC) Stable on ICU/PCU level of care Insurance
Hospitalized, needing cardiac monitoring and/or
Inpatient status
pulse oximetry, q4h checks/interventions
Med-surg
Hospitalized, needing cardiac monitoring and/or
+
pulse oximetry, q4h checks/interventions,
Increasing level of care

telemetry Observation status

anticipated discharge within 72h (or 2 midnights
for Medicare)
Skilled Short term Skilled needa
Nursing Secured Custodial careb with varying degrees of security
Long Insurance
Facility Wanderguard based on ability to elope and safety risk if
term
(SNF) Non-secured elopement occurs
Independent (or have
Acute Rehabilitation Unit (ARU) >3h of PT/OT per day someone available to Insurance
assist) in iADLs
Residential Care Secured Long-term housing, meals, and assistance with
Independent in ADLs
Facility for the (Memory) medication self-administration, but no skilled Money
Elderly (RCFE)c Non-secured needs providedd Independent in ADLs/iADLs
Insurance or
Substance rehabilitation Facilities with daily group programs Independent in ADLs/iADLs
money
For patients experiencing homelessness (services
Recuperative care such as physical therapy, addiction therapy, and Independent in ADLs/iADLs
wound care can be done through home health)
Section-8 Housing Long-term subsidized housing Independent in ADLs/iADLs Money
Shelter Conducts medical care by self Independent in ADLs
Home + home health Care by self + help from family/friends/caregivers

a. Medicare defines skilled need as IV antibiotics, daily complex wound care, speech therapy, PT/OT, first-time tube feeds comprising >26% of daily nutritional need
b. Medicare defines custodial care as care that helps you with usual daily activities, like getting in and out of bed, eating, bathing, dressing, and using the bathroom.
It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters.
c. Includes Board & Care (B&C) and Assisted Living Facility (ALF)
d. Some RCFEs can accommodate ADL dependence for an additional fee