I got a confusing order yesterday and I can't seem to find the answer. We had a pt with a Hx of ruptured AVM with normalized cranial pressures following repair & placement of VP shunt. The pt is 4 mo post-op with no new neuro deficits. Pt presented in the ER with a complain of headache [3 out of 10] - temp 99 oral. No other complaints - physical exam within the baseline for previous hospitalization [per old charts]. Scalp and abdominal wounds are well healed with no s/s of infection. ER doctors decided to admit for 23 hours observation merely as a precaution. I received the pt 3 hours later [don't ask why - I can't explain the delay]. Temp is now 101.5 orally with no neuro changes. No GI, GU or pulmonary symptoms. I called the neurosurgeon and asked if he would like Tylenol, blood cultures, UA, septic labs, etc. He said "well certainly not in that order. EVERYONE knows that you do the work up first and THEN you give Tylenol."
Okay, call me stupid but I can't NOT find the rationale for the delay in giving Tylenol. I don't see any indications that is interfers with cultures or that it would be contraindicated with AVM, VP shunts or mask neuro changes. Does EVERYONE know what I am missing?
Jun 30, '09
Only reason I can think of delaying Tylenol in this pt would be that it would mask a fever. But the pt already has a fever, why let it get worse? Obviously this pt will be getting abx at some point, but not till after cultures are taken, which you clearly know.
The poor pt will need SOME therapeutic measure soon. If not abx to start, why not give a little acetaminophen?
Sorry, I have no further insights. If there IS a rationale, I'd be curious...
Jul 3, '09
That is a great question...I remember in ICU, our docs said the same thing about doing labs before giving just about anything, but I never questioned their rationale. I would be interested in knowing. Maybe someone can ask a doc why...
Jul 3, '09
I have asked a dozen people and, while many have heard this, no one has been able to give me an educated or verifiable answer. Could it be that this is just one of those 'myths' that get perpetuated?
Jul 4, '09
The only thing I would take cultures before giving is antibiotics which could alter the results. I cannot see any rationale for holding tylenol - why don't you ask that doctor?
Jul 4, '09
That make no sense, whatsoever. If you KNOW the patient has a fever, why would you risk further acceleration of the metabolic rate and fluid volume deficit (10-12% for every 1 degree of celsius) by not treating it??
I would wonder what the blood glucose was, though...I would be concerned with a fever, coupled with elevated blood glucose potentially expanding any brain issues, if that is what was going on.
Other than that, yeah, I'm with you...order makes no sense.
Jul 5, '09
I finally saw Dr X again and asked him about the order. I told him that I had not been able to find anything in my reference books but that I was very interested in understanding the effects of Tylenol in this particular case. At first, he just stuttered, then he tried to deny the order and finally he just said "Look it up for yourself and you might learn something!"
I politely told him that I intended to keep looking for the answer but I am convinced that this is just the hospital equivalent of some 'old wives tale' - but I will keep researching it!
As for the question about blood sugars, the patient did not have a history of DM so no routine Accuchecks were done outside of the ER. The blood glucose component of the CMP drawn at the time of my work up was 151. After the 23 hours of observation with no development of additional symptoms, the patient was discharged with a diagnosis of FUO.
Jul 6, '09
Good for you for holding him accountable. I asked one of my gf's who's in the CRNA program with me, and is also an FNP, and she agrees with me - fever + BG @ 151 = expanding ischemia and hypermetabolic state complicating anything else going on.
Given the history, don't be surprised if you see this patient again soon. My "gut" tells me there's something going on there, even if it's not clinically or diagnostically evident.
Jul 7, '09
I didn't think we should have discharged him with no clear answer about the cause of the fever -- I hope you are wrong but I will let you know if he is readmitted!
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