Medical Pearls

Replace Magnesium Before Potassium

Always correct magnesium deficiency before addressing hypokalemia, as low magnesium impairs potassium repletion and can worsen arrhythmias.

Colace (Docusate) Is Ineffective

Docusate is no better than placebo for constipation; use polyethylene glycol (MiraLAX) or lactulose for better results.

Check Vitamin D in Osteoporosis

Screen for vitamin D deficiency in osteoporosis patients, as supplementation (e.g., 800-2000 IU daily) improves calcium absorption and reduces fracture risk.

Avoid PPIs Long-Term Without Indication

Proton pump inhibitors (PPIs) increase risks of C. difficile, fractures, and pneumonia; taper or stop if no clear indication like GERD or ulcer disease.

Use Lactated Ringer’s Over Normal Saline

For fluid resuscitation, prefer lactated Ringer’s to avoid hyperchloremic acidosis from normal saline in large volumes.

Hold Metformin in AKI

Discontinue metformin in acute kidney injury (AKI) or when eGFR <30 to="" prevent="" lactic="" acidosis;="" reassess="" renal="" function="" before="" restarting.<="" p="">#Renal

Treat UTI Based on Local Antibiograms

Choose antibiotics for urinary tract infections based on local resistance patterns to avoid treatment failure (e.g., avoid nitrofurantoin in pyelonephritis).

Use Beta-Blockers Early in MI

Administer beta-blockers within 24 hours of myocardial infarction (if no contraindications) to reduce mortality and reinfarction risk.

Avoid Sliding Scale Insulin Alone

For inpatient diabetes management, combine basal insulin (e.g., glargine) with sliding scale to prevent hyperglycemia and hypoglycemia swings.

Check TSH in Unexplained Hyponatremia

Hypothyroidism can cause hyponatremia; order thyroid function tests in patients with low sodium and no obvious cause.

Start DVT Prophylaxis Promptly

Initiate VTE prophylaxis (e.g., heparin or enoxaparin) within 24 hours of admission for at-risk patients unless contraindicated.

Use High-Dose Statins in ACS

For acute coronary syndrome, start high-intensity statins (e.g., atorvastatin 80 mg) immediately to reduce LDL and stabilize plaques.

Avoid Benzodiazepines in Delirium

Benzodiazepines worsen delirium in hospitalized patients; use antipsychotics like haloperidol or non-pharmacologic measures instead.

Monitor for Hypoglycemia with Octreotide

When using octreotide for variceal bleeding, check glucose frequently, as it can cause hypoglycemia by suppressing glucagon.

Treat Alcohol Withdrawal Early

Start benzodiazepines (e.g., lorazepam) at the first sign of alcohol withdrawal to prevent seizures and delirium tremens.

Use IV Fluids Cautiously in CHF

In heart failure exacerbations, limit IV fluids to avoid volume overload; use diuretics like furosemide for decongestion.

Check Ferritin in Anemia Workup

In anemia, measure ferritin and iron studies to differentiate iron deficiency from anemia of chronic disease before transfusing.

Avoid NSAIDs in CKD

Nonsteroidal anti-inflammatory drugs can worsen renal function in chronic kidney disease; use acetaminophen for pain instead.

Start Antibiotics Within 1 Hour for Sepsis

Administer broad-spectrum antibiotics within 60 minutes of sepsis recognition to improve survival rates.

Use Low-Dose Dopamine Sparingly

Low-dose dopamine for renal perfusion is outdated and ineffective; focus on fluid resuscitation and addressing underlying causes in AKI.

Correct Hypomagnesemia to Stop Torsades

In torsades de pointes, give 2 g IV magnesium sulfate over 5-10 minutes, even if magnesium levels are normal, to stabilize cardiac membranes.

Use Furosemide Stress Test for AKI Prognosis

In acute kidney injury, a furosemide stress test (1-1.5 mg/kg IV) can predict progression to severe AKI or need for dialysis based on urine output response.

Avoid IV Haloperidol in Prolonged QT

For delirium in patients with QTc >500 ms, avoid IV haloperidol due to arrhythmia risk; consider quetiapine or trazodone instead.

Check Anti-Xa Levels for LMWH Dosing

In obese or renally impaired patients on enoxaparin, monitor anti-Xa levels to ensure therapeutic dosing for VTE treatment or prophylaxis.

Use Apixaban Over Warfarin in ESRD

For anticoagulation in end-stage renal disease, prefer apixaban (5 mg BID, or 2.5 mg BID if age >80 or weight <60 kg)="" to="" avoid="" warfarin’s="" variable="" inr="" control.<="" p="">#Renal

Consider Heparin Resistance in HIT

In suspected heparin-induced thrombocytopenia (HIT), if PTT doesn’t respond to heparin, calculate the 4T score and switch to argatroban or fondaparinux promptly.

Add Thiamine Before Glucose in Alcoholics

Administer thiamine (100 mg IV) before any glucose-containing fluids in alcoholics to prevent Wernicke’s encephalopathy.

Use IV Albumin in SBP

In spontaneous bacterial peritonitis, give IV albumin (1.5 g/kg on day 1, 1 g/kg on day 3) alongside antibiotics to reduce renal failure risk and mortality.

Avoid Beta-Blockers in Cocaine-Related Chest Pain

In chest pain from cocaine use, beta-blockers can cause unopposed alpha stimulation and worsen vasoconstriction; use benzodiazepines and nitroglycerin.

Check Serum Osmolality in Hyponatremia

In euvolemic hyponatremia, calculate serum osmolality to rule out pseudohyponatremia from hyperlipidemia or hyperproteinemia before starting fluid restriction.

Use High-Flow Nasal Cannula in Pneumonia

For hypoxemic respiratory failure in pneumonia, try high-flow nasal cannula before non-invasive ventilation to reduce intubation rates.

Monitor for Rebound Hypertension with Clonidine

When stopping clonidine in hypertensive patients, taper gradually and monitor for rebound hypertension within 24-48 hours.

Consider Dexmedetomidine for Refractory AWS

In alcohol withdrawal syndrome unresponsive to high-dose benzodiazepines, dexmedetomidine can reduce autonomic hyperactivity without respiratory depression.

Use Low-Dose PPI for GI Bleed Prophylaxis

For stress ulcer prophylaxis in ICU patients, low-dose PPI (e.g., omeprazole 20 mg daily) is as effective as high-dose with less C. difficile risk.

Check Procalcitonin to Guide Antibiotics

In suspected bacterial infections, use procalcitonin levels to guide antibiotic duration or de-escalation, especially in COPD exacerbations or sepsis.

Avoid Loop Diuretics in Early AKI

In early acute kidney injury, avoid loop diuretics unless volume overload is present, as they may worsen renal perfusion in prerenal states.

Use IV Iron in Heart Failure with IDA

In heart failure with iron deficiency anemia, IV iron (e.g., ferric carboxymaltose) improves functional capacity and reduces hospitalizations, even if hemoglobin is normal.

Suspect SIADH in Malignancy

In cancer patients with hyponatremia, suspect syndrome of inappropriate antidiuretic hormone (SIADH) and check urine sodium/osmolality before fluid restriction or tolvaptan.

Delay Antibiotics in Stable Pancreatitis

In acute pancreatitis without cholangitis or necrosis, delay antibiotics unless infection is confirmed, as prophylaxis increases resistance risk.

Use Vasopressin Sparingly in Septic Shock

In septic shock, add vasopressin (0.03 units/min) only if norepinephrine doses escalate (>0.5 mcg/kg/min) to reduce catecholamine requirements and spare receptors.

Urine Anion Gap for Hyperchloremic Acidosis

In hyperchloremic metabolic acidosis, calculate urine anion gap (Na⁺ + K⁺ - Cl⁻). A negative gap suggests renal tubular acidosis type 1 or 4, often missed in workups.

Esmolol for Refractory VFib

In ventricular fibrillation unresponsive to defibrillation and amiodarone, consider esmolol (500 mcg/kg bolus, then 50-100 mcg/kg/min) to blunt catecholamine surge and improve ROSC.

Avoid Bicarbonate in Lactic Acidosis Unless pH <7.1< h3="">

In lactic acidosis, withhold sodium bicarbonate unless pH <7.1, as="" it="" can="" paradoxically="" worsen="" intracellular="" acidosis="" and="" increase="" co2="" production.<="" p="">#CriticalCare

Check Serum Tryptase in Anaphylaxis Mimics

In suspected anaphylaxis with atypical features, measure serum tryptase within 4 hours to confirm mast cell activation or rule out mimics like carcinoid syndrome.

Use Glucagon for Beta-Blocker Overdose

For beta-blocker overdose with bradycardia and hypotension, give glucagon (3-10 mg IV bolus, then 2-5 mg/h) to bypass beta-receptors and increase cardiac output.

Suspect Hypophosphatemia in Refeeding Syndrome

In malnourished patients starting nutrition, monitor phosphate daily for 72 hours; hypophosphatemia (<2.5 mg="" dl)="" can="" cause="" arrhythmias="" or="" respiratory="" failure.<="" p="">#Nutrition

Lidocaine for Neurogenic Pulmonary Edema

In neurogenic pulmonary edema (e.g., post-subarachnoid hemorrhage), IV lidocaine (1-2 mg/kg) can reduce sympathetic surge and improve oxygenation.

Avoid Kayexalate in Hyperkalemia with CKD

Sodium polystyrene sulfonate (Kayexalate) is ineffective and risks intestinal necrosis in CKD; use loop diuretics instead.

Check Serum Cortisol in Refractory Hypoglycemia

In hypoglycemia unresponsive to glucose, measure random cortisol to screen for adrenal insufficiency, especially in patients with autoimmune history.

Use Methylene Blue in Vasoplegic Shock

For vasoplegic shock (e.g., post-cardiac surgery), methylene blue (1-2 mg/kg IV over 20 min) can restore vascular tone by inhibiting nitric oxide synthase.

Suspect Copper Deficiency in Myelopathy

In patients with unexplained myelopathy or ataxia, check serum copper and ceruloplasmin, as deficiency mimics B12 deficiency and is often dietary or post-bariatric surgery.

Avoid High-Dose Steroids in Acute Gout with AKI

In gout with acute kidney injury, high-dose steroids can worsen fluid retention; use colchicine (1.2 mg, then 0.6 mg 1 hour later) or low-dose prednisone (10-20 mg).

Monitor for Hypokalemia with High-Dose Aztreonam

High-dose aztreonam (>6 g/day) for multidrug-resistant infections can cause hypokalemia; check potassium levels every 48 hours.

Use N-Acetylcysteine for Non-Acetaminophen ALF

In acute liver failure not due to acetaminophen, N-acetylcysteine (150 mg/kg over 1 hour, then 50 mg/kg over 4 hours) may improve transplant-free survival.

Check Serum Ascorbate in Scurvy Mimics

In patients with petechiae, gingival bleeding, or poor wound healing, measure serum ascorbate to rule out scurvy, often missed in alcoholics or elderly with poor diets.

Avoid Dextrose in Early TBI

In traumatic brain injury within the first 24 hours, avoid dextrose-containing fluids to prevent hyperglycemia, which worsens cerebral edema and outcomes.

Use IV Lipid Emulsion for Local Anesthetic Toxicity

For bupivacaine or lidocaine toxicity with seizures or arrhythmias, give 20% lipid emulsion (1.5 mL/kg bolus, then 0.25 mL/kg/min) to sequester the drug.

Suspect Zinc Deficiency in Chronic Diarrhea

In persistent diarrhea with skin lesions or poor wound healing, check serum zinc; deficiency can mimic acrodermatitis and is common in Crohn’s or short gut syndrome.

Consider Vasopressin in Amiodarone-Induced Hypotension

Amiodarone’s alpha-blocking effects can cause hypotension; low-dose vasopressin (0.01-0.04 units/min) can stabilize pressure without increasing arrhythmias.

Test for Porphyria in Unexplained Abdominal Pain

In recurrent, severe abdominal pain with neuropsychiatric symptoms, check urine porphobilinogen during an attack to screen for acute intermittent porphyria.

Check Serum Manganese in Cholestatic Jaundice

In prolonged cholestasis (e.g., primary biliary cholangitis), measure serum manganese; accumulation can cause parkinsonism or neurotoxicity, often misdiagnosed as hepatic encephalopathy.

Use IV Ascorbic Acid in Methemoglobinemia

For methemoglobinemia (MetHb >20%), give IV ascorbic acid (1-2 g q6h) as an adjunct to methylene blue in G6PD-deficient patients, where methylene blue is less effective.

Suspect Baclofen Toxicity in Coma with Normal Labs

In unexplained coma with normal CT and labs, consider baclofen toxicity; it causes profound CNS depression and may require hemodialysis for clearance.

Avoid Phenylephrine in Septic Shock with AKI

Phenylephrine can worsen renal vasoconstriction in septic shock with acute kidney injury; prefer norepinephrine or vasopressin for better renal perfusion.

Test for Hereditary Angioedema in Refractory Angioedema

In angioedema unresponsive to antihistamines or steroids, measure C4 and C1 esterase inhibitor levels to screen for hereditary angioedema, often triggered by ACE inhibitors.

Use IV Magnesium for Acute Porphyria Attacks

In acute intermittent porphyria with severe pain or seizures, give IV magnesium sulfate (2 g q12h) to stabilize neuronal excitability alongside hemin.

Check Serum Selenium in Cardiomyopathy

In dilated cardiomyopathy with no clear etiology, measure selenium levels; deficiency can cause Keshan disease, reversible with supplementation (100-200 mcg/day).

Avoid High-Flow Oxygen in CO Poisoning with Seizures

In carbon monoxide poisoning with seizures, high-flow oxygen (100%) can lower seizure threshold; use normobaric oxygen and benzodiazepines first.

Suspect Thiamine Deficiency in Lactic Acidosis with Normal Perfusion

In lactic acidosis despite adequate perfusion (e.g., post-seizure), give thiamine (200 mg IV) to rule out beriberi, especially in bariatric surgery patients.

Use Octreotide in Chylothorax

For chylothorax (e.g., post-thoracic surgery), octreotide (50-100 mcg SC q8h) reduces lymphatic flow and promotes resolution, often overlooked as a medical option.

Monitor for Hypouricemia in SIADH

In syndrome of inappropriate antidiuretic hormone, check serum uric acid; hypouricemia (<4 mg="" dl)="" strongly="" suggests="" siadh="" over="" other="" causes="" of="" hyponatremia.<="" p="">#Endo

Consider IV Ethanol for Methanol Poisoning

In methanol or ethylene glycol poisoning, if fomepizole is unavailable, IV ethanol (10% solution, 0.6 g/kg/h) can block alcohol dehydrogenase and prevent toxic metabolite formation.

Test for Wilson’s Disease in Young Adults with Cirrhosis

In cirrhosis patients <40 years="" with="" neuropsychiatric="" symptoms,="" check="" ceruloplasmin="" and="" 24-hour="" urinary="" copper="" to="" rule="" out="" wilson’s="" disease,="" often="" missed="" initially.<="" p="">#GI

Use Low-Dose Naloxone for Opioid-Induced Pruritus

For opioid-related itching without overdose, give naloxone (0.04 mg IV q4h) to relieve symptoms without reversing analgesia.

Suspect Biotin Deficiency in Parenteral Nutrition

In patients on long-term total parenteral nutrition with alopecia or dermatitis, check biotin levels; deficiency mimics zinc deficiency and requires supplementation (60-100 mcg/day).

Avoid IV Fluids in Cerebral Salt Wasting

In cerebral salt wasting syndrome (post-neurosurgery), aggressive IV fluids can worsen natriuresis; use fludrocortisone (0.1-0.2 mg/day) to retain sodium.

Check Plasma Free Hemoglobin in Hemolysis

In suspected intravascular hemolysis (e.g., post-valve surgery), measure plasma free hemoglobin; levels >50 mg/dL confirm hemolysis and guide transfusion decisions.

Use IV Vitamin K in Coagulopathy with Cholestasis

In cholestatic liver disease with coagulopathy, give IV vitamin K (10 mg daily for 3 days) before oral, as fat malabsorption limits oral absorption.

Suspect Pantothenate Kinase Deficiency in Dystonia

In young adults with dystonia and basal ganglia changes on MRI, consider pantothenate kinase-associated neurodegeneration; check serum ferritin and genetic testing.

Use Hypertonic Saline Bolus in Severe TBI Hyponatremia

In traumatic brain injury with hyponatremia (Na <130 meq="" l)="" and="" rising="" icp,="" give="" 3%="" hypertonic="" saline="" (250="" ml="" bolus)="" to="" correct="" sodium="" reduce="" cerebral="" edema.<="" p="">#CriticalCare