BCCCP common mistakes
BCCCP · Understand the traps and how to avoid them.
Writes the amiodarone maintenance infusion as 1 mg/min for the full 24 hours after the 150 mg/10 min load, instead of stepping down to 0.5 mg/min after the first 6 hours.
The two-step maintenance regimen (1 mg/min × 6 h, then 0.5 mg/min × 18 h, max 2.2 g/24 h) gets mentally collapsed into a single rate, especially when the order is transcribed from memory at the end of a shift.
What to do instead
Write the regimen as two timed line items with explicit start/stop times and a stated 24-hour maximum; before verifying, sum the delivered dose over 24 h (900 mg + 540 mg = 1.44 g) and confirm it is under the 2.2 g cap.
Labels a high peak airway pressure as parenchymal lung injury and adjusts the vent without first obtaining a plateau pressure (inspiratory hold).
Peak pressure is displayed continuously while plateau requires an active maneuver, so the resistive component (tube, secretions, bronchospasm) gets attributed to the alveoli.
What to do instead
Always pair peak with plateau: a peak–plateau gradient >5–10 cm H2O points to the airway (suction, check tube, bronchodilators), while a plateau >30 cm H2O is the number that triggers lung-protective tidal volume reduction.
Gives a 'standard' second-line antiepileptic load in convulsive status epilepticus, e.g., levetiracetam 1000 mg or phenytoin 500 mg, rather than a full weight-based load.
Maintenance-dose numbers are more familiar than acute loading doses, and the urgency of the situation pushes toward giving 'something' quickly.
What to do instead
Memorize the loading set as weight-based with caps: levetiracetam 60 mg/kg (max 4500 mg), valproate 40 mg/kg (max 3000 mg), fosphenytoin 20 mg PE/kg (max 1500 mg PE, infuse ≤150 mg PE/min; phenytoin ≤50 mg/min).
Doses vancomycin to a trough of 15–20 mg/L and follows troughs alone rather than AUC24/MIC 400–600.
The older trough-based target is deeply entrenched in habit and in older institutional protocols, and AUC requires two timed levels plus a calculation.
What to do instead
For MRSA with MIC 1 mg/L, target AUC24 400–600 (trough-only sampling is acceptable only when AUC cannot be obtained); order a peak and trough around the 4th dose (or use a Bayesian/precision tool) and document the AUC in the note.
Advances to goal-rate enteral nutrition within 24 hours in a patient with severe malnutrition (low BMI, >10% weight loss, negligible intake for >7–10 days) without checking phosphate, magnesium, and potassium or giving thiamine first.
The 'feed the ICU patient early and fully' message overrides the refeeding-risk screen, and electrolytes are often not rechecked until day 2–3.
What to do instead
Start at 10–20 kcal/h (or ~25% of goal) with volume-based advancement over 3–5 days; give thiamine 100 mg IV before glucose-containing fluids or feeds and recheck Phos/Mg/K every 12 hours for the first 72 hours.
Keeps the renal-impairment dose of a renally cleared drug (e.g., cefepime, piperacillin-tazobactam, levetiracetam) after the patient is started on CRRT, citing the elevated serum creatinine.
The chart label 'renal failure' and the pre-CRRT creatinine anchor the dosing decision, and CRRT clearance is assumed to be negligible.
What to do instead
Treat CRRT as its own clearance category (~20–30 mL/min for small molecules, higher with higher effluent rates); redose to CRRT-specific regimens (e.g., cefepime 2 g q8–12h) and use therapeutic drug monitoring where available for vancomycin and aminoglycosides.
Corrects chronic hyponatremia faster than 8–10 mEq/L in 24 hours (or 18 mEq/L in 48 hours) and has no plan to re-lower the sodium if it overshoots.
Attention is fixed on the seizure risk of the low sodium and on the rising repeat lab, with no ceiling stated in the plan.
What to do instead
State the limit explicitly in the note (4–6 mEq/L/24 h in high-risk patients: chronic, alcohol use, malnutrition, hypokalemia), check sodium every 2–4 hours during active correction, and if overshoot occurs use DDAVP 1–2 mcg plus D5W (the 'DDAVP clamp') rather than waiting.
Stops the insulin infusion when the glucose falls below ~200 mg/dL in DKA and does not add dextrose to the fluids.
The glucose is treated as the therapeutic endpoint instead of the anion gap, and stopping the drip looks like protecting against hypoglycemia.
What to do instead
Add D5 (or D10) to the maintenance fluid when glucose is <200–250 mg/dL and continue insulin at 0.02–0.05 units/kg/h until the anion gap is ≤12 with at least two of pH >7.3, HCO3 ≥15, and AG ≤12; document the resolution criteria used.
Continues unfractionated or low-molecular-weight heparin when the platelet count falls ≥50% with an intermediate or high 4T score, waiting for the PF4 antibody result before acting.
The instinct is to confirm before discontinuing a therapy that is itself antithrombotic, and the classic 5–10 day onset isn't checked against the platelet trend.
What to do instead
Treat a high probability 4T score as an indication to stop all heparin immediately and start a non-heparin anticoagulant (argatroban, bivalirudin, or fondaparinux if stable); withhold platelet transfusions and defer warfarin until platelets >150 × 10^9/L.
Uses a midazolam infusion or scheduled lorazepam as the primary sedative for a mechanically ventilated adult, then escalates the dose for persistent agitation.
Benzodiazepines are the reflex choice for ventilator dyssynchrony and agitation, and their accumulation (especially with renal or hepatic dysfunction, and propylene glycol with lorazepam) is not linked to the worsening sedation.
What to do instead
Use analgesia-first, then a non-benzodiazepine (propofol or dexmedetomidine) targeting a light RASS; reserve benzodiazepines for alcohol/benzodiazepine withdrawal, seizure control, or neuromuscular blockade, and reassess daily for delirium with CAM-ICU.