Transcript Updates in Hospital Medicine 2013

Updates in Hospital Medicine
2013
Kendall Rogers, MD CPE FACP SFHM
Associate Professor and Chief
Division of Hospital Medicine
University of New Mexico
School of Medicine
Disclosures
No disclosures to report.
Acknowledgements
• Michelle Mourad
• Hospital Medicine Journal Club
• Anthony Worsham, Sheila Modi, and Jens
Langsjoen
Updates in Hospital Medicine 2013
Updates in Hospital Medicine 2013
• Articles From Late 2012 and 2013
Process:
•
Reviewed and stole from SHM
Update in Hospital Medicine
2013
•
Reviewed all articles presented
at Division of Hospital Medicine
Journal Club
•
CME collaborative review of
journals
▪ Including ACP J. Club, J. Watch, etc.
• 1 in 5 hospitalized patients get a foley, up to
half are inappropriate
• 26% will develop bacteriuria, and 24% of
those will develop CAUTI
• 13,000 deaths per year to CAUTI
• Annual direct medical costs between $340 to
$370 million
• As many as 71% of hospitalized patients on GI
prophylaxis without indication
• Strong correlation between PPI use and
pneumonia and C. Diff infections
• PPI not recommended for adult patients in
non-ICU settings with fewer than 2 risk factors
for bleeding
• A restrictive approach with Hgb cutoff of 7
g/dL has shown improved outcomes
• Holds true to AMI, GI bleed, and surgical
patients
• Cost of blood $700-900 per unit and carries
infectious and noninfectious adverse reactions
• Study showed only 12.6% of patients on nonICU required telemetry and only 7% received
modified management due to telemetry
• Telemetry
– Is resource intensive
– Does not alter management
– Can lead to additional testing
– Increased length of stay in ED
– Reduced hospital throughput
– A false sense of security
• Studies show no difference in readmit rates,
transfers to ICU, LOS, rates of adverse events,
or mortality when frequency reduced
• Charges estimated at $150/patient/day
• Hospital acquired anemia shown to have
worse outcomes
What didn’t make it on SHM:
• Don’t presume a patient to be full code on
admission, have a code status discussion with
all patients to confirm.
OTHER CHOOSING WISELY LISTS
PERTINENT TO HOSPITAL MEDICINE
Other Choosing Wisely Lists:
• ACP
– In the evaluation of simple syncope and a normal
neurological examination, don’t obtain brain imaging
studies (CT or MRI)
– In patients with low pretest probability of venous
thromboembolism (VTE), obtain a high-sensitive Ddimer measurement as the initial diagnostic test;
don’t obtain imaging studies as the initial diagnostic
test.
– Don’t obtain preoperative chest radiography in the
absence of a clinical suspicion for intrathoracic
pathology.
Other Choosing Wisely Lists:
• Palliative Medicine
– Don’t recommend percutaneous feeding tubes in
patients with advanced dementia; instead, offer
oral assisted feeding.
– Don’t delay palliative care for a patient with
serious illness who has physical, psychological,
social or spiritual distress because they are
pursuing disease-directed treatment.
– Don't leave an implantable cardioverterdefibrillator (ICD) activated when it is inconsistent
with the patient/family goals of care.
Other Choosing Wisely Lists:
• Neuro
– Don’t perform imaging of the carotid arteries for
simple syncope without other neurologic
symptoms.
• GI
– For pharmacological treatment of patients with
gastroesophageal reflux disease (GERD), long term
acid suppression therapy (proton pump inhibitors
or histamine2 receptor antagonists) should be
titrated to the lowest effective dose needed to
achieve therapeutic goals.
Other Choosing Wisely Lists:
• Radiology
– Don’t image for suspected pulmonary embolism
(PE) without moderate or high pre-test probability.
– Avoid admission or preoperative chest x-rays for
ambulatory patients with unremarkable history
and physical exam.
Other Choosing Wisely Lists:
• Geriatrics
– Don't use antipsychotics as first choice to treat
behavioral and psychological symptoms of dementia.
– Avoid using medications to achieve hemoglobin
A1c<7.5% in most adults age 65 and older; moderate
control is generally better.
– Don't use benzodiazepines or other sedativehypnotics in older adults as first choice for insomnia,
agitation, or delirium.
– Don't use antimicrobials to treat bacteriuria in older
adults unless specific urinary tract symptoms are
present.
Other Choosing Wisely Lists:
• Echocardiography
– Avoid transesophageal echocardiography (TEE) to
detect cardiac sources of embolization if a source
has been identified and patient management will
not change.
• Nuclear Cardiology
– Don't perform cardiac imaging as a pre-operative
assessment in patients scheduled to undergo lowor intermediate-risk non-cardiac surgery.
Other Choosing Wisely Lists:
• Nephrology
– Avoid nonsteroidal anti-inflammatory drugs
(NSAIDs) in individuals with hypertension or heart
failure or CKD of all causes, including diabetes.
• Nuclear Medicine
– Avoid using a computed tomography angiogram to
diagnose pulmonary embolism in young women
with a normal chest radiograph; consider a
radionuclide lung study (“V/Q study”) instead.
Other Choosing Wisely Lists:
• Vascular Medicine
– Don’t do work up for clotting disorder (order
hypercoagulable testing) for patients who develop
first episode of deep vein thrombosis (DVT) in the
setting of a known cause.
– Don’t reimage DVT in the absence of a clinical
change.
– Avoid cardiovascular testing for patients
undergoing low-risk surgery.
NOW ON WITH THE CASES!
Case 1
76 y.o. patient with COPD, chronic venous insufficiency, previous
C. difficile. One day history of fever, chills…
Pulse 120
BP 94/60
T 102.4
RR 28
WBC 18,000 with
18% bands
Lactate 3
Is there another symptom or sign
that helps predict bacteremia?
Predicting bacteremia based on nurse-assessed food
consumption at the time of blood culture.
Patients meeting
entry criteria
n = 1179
IVH/NPO, n=194
N/G tube feeding, n=134
Exclude: Other causes
of decreased oral
intake
n = 851
Blood Culture +
n = 122
Blood Culture –
n = 729
True positive cultures
well-defined
True Positive
n = 75
Komatsu T et al. J Hosp Med 2012; 7:702-205
Category
Definition
Low
<50% food
consumed
Moderate
High
N
Positive
cultures
% positive
50-80% food
consumed
>80% food
consumed
Komatsu T et al. J Hosp Med 2012; 7:702-205
Category
Definition
N
Positive
cultures
% positive
Low
<50% food
consumed
344
63
18%
50-80% food
consumed
152
6
4%
>80% food
consumed
354
6
1.7%
Moderate
High
Komatsu T et al. J Hosp Med 2012; 7:702-205
The Case continues…..
+
Blood cultures: MRSA
48 hours into hospitalization:
Still febrile, BPs labile and lowish
Is daptomycin better than
vancomycin for MRSA
bacteremia?
Daptomycin versus vancomycin for bloodstream infections due
to methicillin-resistant Staphylococcus aureus with a high
vancomycin minimum inhibitory concentration: a case-control
study.
Design:
Single center, retrospective
MRSA blood culture isolates with vancomycin
minimum inhibitory concentration less than or
equal to 2
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
Outcome
Vancomycin
(n = 118)
Daptomycin
(n = 59)
P
Clinical failure
60-day mortality
Microbiologic
failure
Recurrence of MRSA
bloodstream
infection
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
Vancomycin
(n = 118)
Daptomycin
(n = 59)
Clinical failure
37 (31%)
10 (17%)
.084
60-day mortality
24 (20%)
5 (8%)
.046
Microbiologic
failure
11 (9%)
6 (10%)
.855
Recurrence of MRSA
bloodstream
infection
6 (5%)
2 (3%)
.620
Outcome
P
Moore CL et al. Clin Infect Dis 2012; 54:51-8.
On with the case!
Our patient is treated and discharged but then returns to
the ED increased cough and SOB. Initially on BiPAP, now
on NC.
Afebrile
BP: 135/85
Pulse: 110
O2 sat: 94% on 4L NC
His labs are only notable for a BUN of 35 and a creatinine
of 1.9. He has diffuse loud wheezes on exam and is
difficult to arouse.
Case Presentation
“The patient has a monitored floor bed upstairs
and is just waiting for your admitting orders.”
Where do you think the patient should
be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental status
identify risk for bad outcomes on the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Is there an easy risk score that can
predict poor outcomes in acute
COPD?
Validation of a Novel Risk Score for Severity of
Illness in Acute Exacerbations of COPD
Design:
Validation of a risk score for pts with acute COPD
admitted to hospital, retrospective
cohort
34,699 patients > 40
years old, acute
exacerbations of COPD.
Ability of the BAP-65
score to predict
outcomes, LOS and cost.
B – BUN >25
A – AMS
P – Pulse >109
>65 year old
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
BAP-65 score for COPD risk
Mortality
Mechanical Ventilation
60%
30%
40%
20%
20%
10%
0%
0%
No
risks
Age
only
Two
risks
Three
risks
Four
risks
No
risks
Age
only
Two
risks
Three
risks
Four
risks
B – BUN >25 A – AMS P – Pulse >109 >65 year old
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
BAP-65 score for COPD risk
Conclusion: BAP-65 can be useful in initial triage to predict
MV and mortality. Better at identifying
patients with low risk, who are safe for floor.
Comment: Measurements all present on an initial
assessment, but may leave out other key
information that could improve triage.
Shorr AF, et al. Chest. 2011;140(5):1177-1183.
Where do you think the patient should
be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental status
identify risk for bad outcomes on the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Where do you think the patient should
be admitted?
A. Need an ABG before triage to the floor
B. Regular floor on telemetry
C. His age, pulse, BUN and altered mental
status identify risk for bad outcomes on
the floor
D. Needs the ICU
E. Sounds like an “obs” patient to me
Our case continues...
We start prednisone, Azithromycin and
admit him to the ICU, where he is
intubated for 2 days due to progressive
hypercarbia and extubated on hospital day
#3 and he is moved to the floor.
Two days later his WBC rises to 24, and we
are a little worried this isn’t just the
steroids.
Nurse states pt having loose stools that
smell like C. Diff
Should you believe
her? Can you tell C.
Difficile simply by
its smell ?
Using a dog’s superior olfactory sensitivity to
identify Clostridium difficile in stools and
patients: proof of principle study
• Beagle trained to identify the smell of
C.difficile in stool samples and sit or lie down
with a positive result.
• Performance was tested on 100 stool
samples & 300 patients (30 cases and 270
controls).
Bomers, MK et al. BMJ; 2012:345, 7-9
Test
Sensitivity Specificity
Speed
Cost
Glutamate dehydrogenase (GDH) 70-80%
<90%
Hours
$17
EIA (Toxin A and B)
60-80%
75-99%
Hours
$5-17
PCR (toxin B)
>90%
>95%
Hours
$20-50
Stool cytotoxin of cell culture
70-80%
>97%
2 to >3d
$7-13
Culture for C. difficile
>90%
95-97%
2 to >3d
$10-22
Bomers, MK et al. BMJ; 2012:345, 7-9
Test
Sensitivity Specificity
Speed
Cost
Glutamate dehydrogenase (GDH) 70-80%
<90%
Hours
$17
EIA (Toxin A and B)
60-80%
75-99%
Hours
$5-17
PCR (toxin B)
>90%
>95%
Hours
$20-50
Stool cytotoxin of cell culture
70-80%
>97%
2 to >3d
$7-13
Culture for C. difficile
>90%
95-97%
2 to >3d
$10-22
Nursing Staff
55-82%
77-83%
Minutes
free
Bomers, MK et al. BMJ; 2012:345, 7-9
Test
Sensitivity Specificity
Speed
Cost
Glutamate dehydrogenase (GDH) 70-80%
<90%
Hours
$17
EIA (Toxin A and B)
60-80%
75-99%
Hours
$5-17
PCR (toxin B)
>90%
>95%
Hours
$20-50
Stool cytotoxin of cell culture
70-80%
>97%
2 to >3d
$7-13
Culture for C. difficile
>90%
95-97%
2 to >3d
$10-22
Nursing Staff
55-82%
77-83%
Minutes
C. Diff Beagle (stool samples)
100%
100%
Minutes
C. Diff Beagle (person)
83%
98%
Minutes
free
2 month
training
2 month
training
Take home points: Cute, low cost, cute alternative to laboratory
testing with similar sensitivity and specificity to commonly
available tests.
Bomers, MK et al. BMJ; 2012:345, 7-9
Our case continues...
The nurse asks if the patient had been on
probiotics, would that have prevented this
episode of C. Diff?
Probiotics
• Meta-analysis of 23 trials (4213 participants)
• Many different strains and doses
• Suggests that probiotics decrease CDAD by
64%
• Incidence of 2.0% with probiotics and 5.5%
without
• ‘Moderate’ confidence probiotics decreases
CDAD
• Hospitalists This well done meta-analysis
supports the contention that probiotics can
help prevent C. difficile-associated diarrhea,
although they do not appear to affect the rate
of C. difficile infection itself. The dose,
preparation, and timing of probiotics,
however, remains unclear as well as which
patients would most benefit from this
prophylactic therapy.
BUT WAIT!
• Lancet. 2013 Aug 7. doi:pii: S0140-6736(13)61218-0. 10.1016/S01406736(13)61218-0. [Epub ahead of print]. PMID: 23932219
• Study design
– Multicenter double blind RCT (2900 participants)
• Population
– 65yo inpatients on abx within past 7 days.
• Intervention (vs placebo)
– L. acidophilus, B. bifidum, B. Lactis, 1-60b cfu
• Outcomes
– AAD or CDAD
Good parts of study design
• Blinding: good
• Randomization: good
• Intervention: dosing was good (billions)…
Problems with study design
• They selected for patients that don’t get AAD
– Pts on abx during last 7 days without diarrhea on
admission
– 7 day ‘grace period’ catches many patients on tail end of
abx therapy
– Patients already with AAD all excluded
– Study incidence of AAD 10% (should be 20-30%)
• C diff incidence was too low
– C diff incidence 1% (predicted 4%)
– % of AAD that was 2/2 C diff
• 7%, usually closer to 25%
– Only 57% of AAD events sent for c diff testing
Problems with study design
• Poor compliance (50% in both groups)
• Unknown % already on probiotics (>5%)
– but 200 (>3%) excluded for refusing to stop
probiotic
• Lactobacillus acidophilus
Wrong strains?
• Lactobacillus acidophilus and Bifidobacterium
– No good trials on L. acidophilus
– Similar mixtures: 3 small (n<100) trials, small effect
• McFarland meta-analysisOnly L. Rhamnosus GG, S. Boulardii and probiotic
mixtures were effective on subgroup analyses
• Johnston meta-analysis
Only LGG, L Coagulans, and S. Boulardii effective in
subgroups
Our patient asks about the effectiveness of stool
transplant for curing C. difficile infection.
What is the effectiveness of fecal
bacteriotherapy (i.e. stool transplant)
in the management of C. difficile?
Systematic Review of Intestinal Microbiota
Transplantation (Fecal Bacteriotherapy) for Recurrent
Clostridium difficile Infection
Design: Systematic review
• 27 articles involving 317 patients
• No RCT in this systematic review
• All patients had a diagnosis of
recurrent or relapsing CDI
Gough, E et al. CID; 2012: 53, 994-1002
Effectiveness of fecal bacteriotherapy
Cure Rates
Recurrence
Rates
Cost for 10 day tx
(cost per tablet)
Metronidazole
73-94%
5-25%
$21 ($0.67)
Vancomycin
84-94%
7-25%
$1,280 ($32)
Fidaxomycin
80-90%
15%
$2700 ($135)
Treatment
Gough, E et al. CID; 2012: 53, 994-1002
Effectiveness of fecal bacteriotherapy
Cure Rates
Recurrence
Rates
Cost for 10 day tx
(cost per tablet)
Metronidazole
73-94%
5-25%
$21 ($0.67)
Vancomycin
84-94%
7-25%
$1,280 ($32)
Fidaxomycin
80-90%
15%
$2700 ($135)
Stool transplant
88-92%
4%
~$1500
Treatment
• Nearly all (92%) experienced resolution, most (88%) after only 1
treatment.
• Related donors better than unrelated, enema better than upper GI tract,
and larger volumes of stool were better than lower volumes.
• Side effects of stool transplantation were rare and relapse of C.
difficile after treatment was rare.
Gough, E et al. CID; 2012: 53, 994-1002
Take home points
Start:
–Questioning bacteremia when hamburger sign +
–Referring those with relapsing C.difficile for stool transplant
–A beagle training camp in Albuquerque to C. Diff detection
Consider:
– Daptomycin in MRSA infection with vancomycin MIC ≥2
– BAP-65 of 0 to identify low risk patients
– Probiotics in patient on antibiotics to prevent C. Diff
Stop:
• Doing everything on the Choosing Wisely Lists
Case 2
65 y.o. patient with early Parkinson’s Disease
presents with four hours of shortness of breath and
chest pain.
BP 140/80, P 96, T 37.9, RR 22, SaO2 92%
Exam: RV heave, increased P2
WBC 11,300
NT-proBNP 1568
D-dimer 3560
The case continues…
Blood pressure falling, oxygen requirement
increasing…
Thrombolytics?
Thrombolytic therapy in unstable patients with acute
pulmonary embolism: Saves lives but underused.
Design:
Retrospective database analysis
1999-2008 Nationwide Inpatient Sample
2 million patients with PE
72,230 patients with unstable PE
21,390 (30%) received
thrombolytics
Stein PD and Matta F. Am J Med 2012; 125:465-470
PE Attributable Case Fatality
Rate in Unstable Patients (%)
Mortality attributable to PE
50%
42%
40%
27%
30%
20%
10%
8%
2.70%
0%
Thrombolytic No Thrombolitic
Therapy
Therapy
n=9,810
n=2,600
All Patients
Thrombolytic No Thrombolitic
Theray
Therapy
n=2,590
n=600
IVC Filter Only
Figure 3. In hospital death attributable to pulmonary embolism in unstable patients
with pulmonary embolism. All unstable patients (left), Unstable patients who
received a vena cava filter (right). Differences of case fatality rate, P <0.001.
PE – pulmonary embolism; VC – vena cava
Stein PD and Matta F. Am J Med 2012; 125:465-470
Case continues…..
The patient undergoes successful
thrombolysis, placement of an IVC filter, and is
being managed with enoxaparin SC. Warfarin
is initiated.
“But wait a minute, this patient is at risk for
falls. Can we safely use warfarin?”
Risk of falls and major bleeds in patients on oral
anticoagulation therapy
Design:
Prospectice cohort study, 515 patients
Definition of high risk:
If patients answered yes to either of the
following questions:
• Did you fall during the past year?
• If not, then, Did you notice any problem
with gait, balance, or mobility?
Donze J et al. Am J Med 2012; 125:773-778.
Outcome
High fall risk
(n=308)
Low fall risk
(n=207)
Notes
Crude incidence of major
bleeds
Gastrointestinal bleeds
Intracerebral bleeds
Fatal bleed
Bleed in context of INR >
3.0
Fall-related bleed
Donze J et al. Am J Med 2012; 125:773-778.
Outcome
High fall risk
(n=308)
Low fall risk
(n=207)
Notes
Crude incidence of major
bleeds
8.0 per 100
patient years
6.8 per 100
patient years
P = 0.64
Gastrointestinal bleeds
11 events
2 events
Intracerebral bleeds
2 events
4 events
Fatal bleed
3 events
2 events
Bleed in context of INR >
3.0
8 events
1 events
Fall-related bleed
1 event
2 events
All nonfatal
subdural
hematomas
Donze J et al. Am J Med 2012; 125:773-778.
Case continues…..
The patient does well. INR on warfarin 2.5. Ready for
discharge. As we prepare the discharge summary,
we note that the platelet count on admission was
230,000 then 3 days into the course was 130,000 and
stabilized at that level.
Should we worry?
Predictive value of the 4Ts scoring system for heparininduced thrombocytopenia: a systematic review and
meta-analysis
Table 1. The 4Ts scoring system for HIT
4Ts category
Thrombocytopenia
2 points
Platelet count fall > 50%
and platelet nadir ≥ 20
1 point
0 points
Platelet count 30%-50% or Platelet count fall < 30% or
platelet nadir 10-19
platelet nadir < 10
Thrombosis or other
sequelae
Consistent with days 5-10
fall, but not clear (eg,
Clear onset days 5-10 or
missing platelet counts);
platelet fall ≤ 1 day (prior onset after day 10; or fall ≤
heparin exposure within 30 1 day (prior heparin
Platelet count ≤ 4 days
days)
exposure 30-100 days ago) without recent exposure
New thrombosis
(confirmed); skin necrosis; Progressive or recurrent
acute systemic reaction
thrombosis; nonpostintravenous
necrotizing (erythematous)
unfractionated heparin
skin lesions; suspected
bolus
thrombosis (not proven)
None
Other causes of
thrombocytopenia
None apparent
Timing of platelet count
fall
Possible
Definite
Cuker A et al. Blood 2012; 120: 4160-4167
Category
Score
HIT+/total (%)
Predictive value
(95% CI)
High
6-8 points
128/253 (50.5%)
Positive PV 0.64,
(0.40-0.82)
Intermediate 4-5 points
148/1251 (11.8%) Positive PV 0.14
(0.09-0.22)
Low
13/1712 (0.8%)
1-3 points
Negative PV 0.998
(0.97-1.00)
Cuker A et al. Blood 2012; 120: 4160-4167
Case continues…..
Six months later the patient is admitted for an unrelated
problem. She wonders…..
Aspirin for preventing the recurrence of venous
thromboembolism
Design:
Multicenter RCT
403 patients with first
unprovoked VTE
Treated with at least 6months with oral
anticoagulation
ASA 100mg
Placebo
Becattini C et al. N Engl J Med 2012; 366:1959-1967.
Outcome
Aspirin Placebo
(n=205) (n=197)
Recurrent VTE
28
43
Pulmonary
embolism
11
14
Fatal PE
1
1
Bleeding
Major bleeding
4
4
1
1
Death
6
5
Arterial event
8
5
Hazard ratio
P value
(95% CI)
0.58
(0.36-0.93)
0.70
(0.32-1.54)
0.98
(0.24-3.96)
1.04
(0.32-3.42)
1.43
(0.47-4.37)
0.02
0.37
0.97
0.95
0.53
Becattini C et al. N Engl J Med 2012; 366:1959-1967.
On with the case!
Several weeks later walking
through the ED we notice our
patient lying on a gurney.
She’s been feeling nauseated
for days and throwing up
coffee grounds.
Her hct drops steadily
She develops melena…
What is the optimal
transfusion threshold for
patients with acute UGIB?
Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
Design:
Single site, non-blinded study, included those with
suspected liver disease and potential variceal bleeding
921 patients with severe acute
upper GI bleed
All patients received 1 unit PRBCs
prior to Hgb measurement and
prompt endoscopy within 6 hours
Transfusion for
target Hgb 7
Transfusion for
target Hgb 10
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Optimal Transfusion in UGIB
Results:
Transfusion for target
Hgb 7
95% Survival
10% Rebleeding
Transfusion for target
Hgb 10
91% Survival
16% Rebleeding
• Survival at 6 weeks was significantly higher in the
restrictive target group compared to the liberal
target.
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Optimal transfusion in UGIB
Conclusion: In HD stable patients with acute UGIB
(even variceal), a target Hgb of 7 is
associated with better outcomes.
Comment: Did not apply to exsanguinating patients
or those in shock. Patients also received
endoscopy in 6 hours for a possible
intervention.
Villanueva C et al. N Engl J Med 2013; 368: 11-21.
Our case continues...
We decide to hold off on
transfusion.
Endoscopy demonstrates several
small, clean-based, shallow peptic
ulcer, most likely from her recent
aspirin use.
• Extendend prophylaxis for 28 days with aspirin
was noninferior to and as safe as dalteparin
for the prevention of VTE after THA in patients
who initially received dalteparin for 10 days.
Take home points
Start:
• Using thrombolytics in patients with unstable PE
Stop:
• Witholding warfarin in patients with a fall risk
• Transfusing patients with an UGIB and a Hbg >7
Consider:
• Using a low 4T’s score to rule out HIT
• Using aspirin after 10 days of LMWH