We wanted to point out just a couple of pearls from the great discussion that was had this morning:
1. A nuanced point regarding HCAP/HAP/VAP – Not every patient who has had contact with the health care system has MRSA and pseudomonas and so we should probably not give everyone vanc/zosyn. The point was made today that the HCAP guidelines were extrapolated from data on VAP. This is why we think of covering for MRSA and Psuedomonas when we treat patients with “healthcare associated risk factors.” If, for example, the patient has ESRD on HD but is not ill appearing and is otherwise low risk that patient may not need to be treated with vanc/zosyn and will probably be fine being treated with CAP coverage. The patient’s severity of illness should guide our treatment in many of these cases. Indeed, if you look up the ATS guidelines for HCAP/HAP/VAP it says “under revision” probably because we are recognizing that the current guidelines are overly aggressive and not everyone is at risk for being infected by multi-drug resistant organisms.
2. Evaluation of the patient with hypercapnia – As Uptodate puts it you can think that either the patient: “won’t breathe, can’t breathe, or can’t breathe enough.”
The respiratory pathway includes:
-The Central Nervous System
-The Peripheral Nervous System
-The Respiratory Muscles
-The Chest Wall and Pleura
-The Upper Airway
Keep that in mind when you are coming up with your differential for hypercapnia!!
See Below from Uptodate.com for a great figure showing this framework and the hypercapnia differential!