Transcript Update in Hospital Medicine 2013

 Transfusion
Medicine
 Anticoagulation
 Therapeutics
 Perioperative Medicine
 Critical Care
 Choosing Wisely
Update in Hospital Medicine 2013
CC: dizzy and black stools
HPI: M.S. is an 78 yo female with 2 day
history of 6 black, foul smelling sticky stools,
and one day history of mild dizziness,
fatigue, DOE and nausea. No vomiting or
syncope.
PHM: HTN, DMII, a-fib, OA
PSH: Cholecystectomy, TKA on R
Meds: Diltiazem, Lisinopril, Metformin,
Warfarin, Acetaminophen, PRN Ibuprofen
about twice per week
Update in Hospital Medicine 2013
SH: lives alone, independent in ADLs,
widowed, non smoker and non drinker
FH: CAD in father who died at 64, son
with CAD post CABG
ROS: otherwise neg, no abd pain, no CP
PE: Gen – NAD, 128/74, 14, 108, 36.6, wt
56 kg
ENT – scleral pallor
CV – Irregular, no Murmur
Update in Hospital Medicine 2013
Pulm – CTA, non labored
Abd – NABS, no masses, mild midepigastric tenderness without G/R
tenderness
Ext – no C/C/E
Nuero – non-focal, A&OX3
Labs – INR 3.6, PTT 31.1, Hb 6.7, HCT 20.1,
BS 187, rest of CBC and CMP WNL
Update in Hospital Medicine 2013
ED Course – 3 units FFP, 2 units RBC, I L
NS, transfer to ICU, 2 16 gauge IV were
placed, GI consult, Pantoprazole bolus
and drip ordered, EGD scheduled for
the following morning, H/H every 6 hours
Update 10 hours later – One more
episode of melena, no N/V, repeat Hb
7.7, VSS, HR 89
Update in Hospital Medicine 2013
What is you RBC transfusion strategy for this
patient?
A. Transfuse 2 units RBC now, cont Q6 hr
H/H, transfuse to a Hb target >9
B. Transfuse 1 units RBC now, cont Q6 hr
H/H, transfuse to a Hb target >9
C. Cont Q6 hr H/H, hold transfusion for
now, transfuse to a Hb target >7
D. GI is on board, let them worry about it!
Update in Hospital Medicine 2013
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Objective – compare restrictive vs liberal transfusion
strategy in UGIB
921 patient with UGIB randomized to liberal (Hb target
>10) or restrictive (Hb >7) transfusion strategy
Exclusions – LGIB, exsanguination, shock, active
coronary syndrome
Endpoint – 6 week mortality
Results – survival in restrictive 95% vs 91 % for liberal (.55
HR, CI .33-.92, p=.02)
Also advantage for restrictive in re-bleeding 10% vs 16%,
p.01)
Take home – better outcomes in UGI bleed with
restrictive strategy, even in variceal bleeding
Update in Hospital Medicine 2013
Further course – The patient remained
stable, no further melena. She received
no further blood products. EGD showed
a GU with a clean base and no active
bleeding, clot or visible vessel. On
hospital day three the patient was
discharged to home on her home
medications except warfarin and
ibuprofen. Pantoprazole 40 mg daily
was added
Update in Hospital Medicine 2013
When should Warfarin be restarted?
A. In one month
B. In 2 weeks
C. In 4 days
D. Never – are you crazy!!
Update in Hospital Medicine 2013
Retrospective cohort study
GIB – 219 restart Warfarin in less than 2 weeks, 180
did not restart within 2 weeks
 Restart Warfarin –
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Mean time 4 days (IQR 2-9 days)
Thromboembolism HR .05 ( CI .01 - .58)
Death .31 (.15 - .62)
GIB 1.32 ( .5-3.57)
Restart group - 0 thromboembolic events
Not restart group – 11 thromboembolic events,
including 3 deaths from CVA
 Take home – restart Warfarin after GIB
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Update in Hospital Medicine 2013
M.S., now 79 and has worsening L
shoulder pain form OA. She was
medically evaluated by her PCP prior to
an elective L total shoulder arthroplasty.
You are consulted in the hospital to
manage her anticoagulation. Her exam
and medications are unchanged. Her 5
mg per day dose of Warfarin was
discontinued 5 days pre-op. Her post
op Hb is 11.8, Cr. 0.5 and INR is 1.0
Update in Hospital Medicine 2013
How would you manage her
anticoagulation?
A. Enoxaparin 1.5 mg/kg sub-q starting
POD#1 and restart Warfarin POD 0
B. Enoxaparin 1.5 mg/kg sub-q starting
POD#2 and restart Warfarin POD 0
C. Enoxaparin 40 mg sub-q starting POD 0
and restart Warfarin POD 0
D. SCDs starting POD 0 and Warfarin
starting POD 0
Update in Hospital Medicine 2013
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Cohort study
2,182 patients on long term Warfarin
Study peri-procedural bleeding associated with LMWH
bridging
1496 received bridging, 686 did not
5.1% bleeding, 2.1%major bleeding
Bridge - 3% major, no bridge -1% major (p=.017)
Major bleeding – Bridging <24 hr post op (HR 1.9, CI 1.6 –
3.4)
No major bleeding <24 hr if not on LMWH
Authors conclusions: bridge only high risk and at 48hr
Cautions – study groups had different characteristics
Update in Hospital Medicine 2013
CC: can’t walk
HPI: S.M is an 72 yo R handed male with a 7 hour
history of difficulty walking. He had difficulty getting
up from the kitchen table and had to hold on to
furniture because of falling to the R. He had
difficulty trying to dial his daughter’s PN. When his
daughter arrived on her way home from work she
noticed slurred speech and called 911
PHM: COPD, HTN, DM2, hospitalized one time in the
past year for AE-COPD
PSH: appendectomy
Meds: fluticasone/salmeterol, tiotropium,
albuterol, amlodipine, metformin, glimepiride
Update in Hospital Medicine 2013
SH: spokes ½ PPD, 50 pack year smoking
history, 2 beers/day, lives with daughter,
independent in ADLs, divorced
FH: NC
ROS: no F/C, cough with yellow sputum,
no CP, DOE for past 2 days at 30 feet,
neuro as above, otherwise neg
PE: labored breathing and anxious
Update in Hospital Medicine 2013
VS: 149/92, 88, 24, 36.8, O2 sat 91% RA
ENT: slightly dry oropharynx
Card: Regular but distant S1S2 w/o
murmur
Pulm: mildly labored with expiratory
wheezing with prolonged expiration
Abd: NABS, soft, NT, no masses
Ext: no C/C, trace pretibial edema
Update in Hospital Medicine 2013
Neuro:A&OX3, mildly slurred speech
without word finding difficultly, no gross
sensory deficits, diminished strength and
coordination in the RUE and RLE, 2+ DTR
patellar bilaterally, absent Achilles DTR
bilaterally
Labs: CPC, CMP, coags all normal
except BS 204
CXR: Hyperinflation, no acute infiltrate
Update in Hospital Medicine 2013
EKG: NSR, RAFB
Head CT: age appropriate atrophy only
ED course: after passing a bedside swallow
eval the patient was given ASA 325 mg
po, methylprednisolone 60 mg IV,
Levofloxacin 750 mg IV and admitted on
your service to the stroke unit on a stroke
protocol with a diagnosis of AE-COPD
and ischemic CVA
Update in Hospital Medicine 2013
What is appropriate anti-plate therapy
for therapy patent?
A. ASA 325 pm PO daily
B. Clopridogrel 75 mg po daily
C. ASA 81 mg po daily plus Clopridogrel
75 mg po daily
D. Consult neuro, they will know what to
do
Update in Hospital Medicine 2013
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7 trails, 39,574 patients, index CVA or TIA
Recurrent CVA –
› Dual vs ASA OR .89 (CI .78-1.01)
› Dual vs Clopidogril 1.01 (.93-1.08)
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ICH –
› Dual vs ASA.99 (.70-1.42)
› Dual vs Clopidogrel 1.49 (1.17-1.82)
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Conclusion – dual therapy is not better
at preventing CVA, but is more likely to
be associated with ICH than Clopidogrel
mono-therapy
Update in Hospital Medicine 2013
Hospital course: The patient’s neuro deficits
remained unchanged. He was continued
on 325 mg ASA daily. He was initiated on
levofloxacin 750 mg po daily to be
continued for a total of 7 days and
prednisone 40 mg daily. His wheezing and
subjective dyspnea improved. His BS on his
home medications plus SS sort acting
insulin were below 180 and above 100. On
day three he is being discharged to acute
rehab.
Update in Hospital Medicine 2013
What is the appropriate duration for the
patients prednisone therapy?
A. 21 day taper
B. 14 days
C. 5 days
D. Let the rehab doc decide
Update in Hospital Medicine 2013
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Short-term vs. conventional glucocorticoid therapy in AECOPD
Randomized, placebo-controlled, double-blinded, noninferiority
314 patients in ED (92% admitted) with severe COPD
(mean FEV1-31%) and AE-COPD, randomized to 5 or 14
day course of 40mg/day of prednisone
No difference in repeat exacerbation at 6 month (5
days=36%, 14 days =37%)
No difference in median time to next exacerbation (5
days pred=45 days until next exacerbation, 14 days =29
days)
No difference in secondary endpoints: death, LOS,
hyperglycemia, FEV1, dyspnea index
Conclusion: Short course prednisone non-inferior to long
course in AE-COPD
Update in Hospital Medicine 2013
What are potential complications of this
patient’s therapy with levofloxacin
A.
B.
C.
D.
Peripheral neuropathy
Tendon damage
Hyperglycemia
Hypoglycemia
Update in Hospital Medicine 2013
Population based study, 78,433 patients,
floroquinolones, macrolides and cephalosporins
 Severe hyperglycemia vs macrolides (per 1,000
patients)
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› Moxifloxacin (6.9 vs 1.6)
› Levofloxacin (3.9)
› Ciprofloxacin (4.0)
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Severe hypoglycemia vs macrolides (per 1,000 patients)
› Moxifloxacin (10 vs 3.7)
› Levofloxacin (9.3)
› Ciprofloxacin (7.8)
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Diabetics using oral fluoroquinolones faced greater risk
of severe dysglycemia.
Update in Hospital Medicine 2013
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FDA required a label changes to warn of risk
for possibly permanent nerve damage
Previously was part of package insert only
IV and oral
Can be permanent and disabling
Onset can be in as little as three days
FDA reporting system cannot calculate risk
Known since 2004
Update in Hospital Medicine 2013
CC: I’ve fallen and I can’t get up
HPI: T.F. is an 86 yo female who fell while getting
back into bed. She tripped over the upturned
corner of a throw rug. She is experiencing pain in
the L groin that radiates down the anterior aspect
of her upper leg. She could not get up but was
able to crawl to her phone and call for help. She
has no other injuries or pain and no syncope. She
had one previous fall 2 years ago.
PHM: HTN, DMII, OA, macular degeneration, CAD
post CABG in 1991, echo 18 mo ago with no WM
abnormalities or significant valvular disease, grade
1 diastolic dysfunction PSH: CABG, TKA on R
Meds: Metoprolol, Lisinopril, HCTZ, Metformin, ASA,
Acetaminophen, Simvastatin
Update in Hospital Medicine 2013
SH: 20 pack year smoking history, quit in
1991, no EtOH, lives in assisted living, walks
with a walker, widowed
FH: NC
ROS: no CP with exertion or at rest, no DOE,
palpitations, orthopnea, PND, pedal
edema, otherwise neg, BS usually <150,
checks one time daily
PE: resting comfortably in ED after 2mg IV
morphine
Update in Hospital Medicine 2013
VS: 108/62, 66, 14, 36.4, O2 sat 97% RA
Head and Neck: NC/AT, neck non tender
CV: Regular S1S2 w/o murmur, bilateral
palpable DP and AT pulses
Pulm: CTA, non-labored
Abd: NABS, soft, NT, no masses
MS: externally rotated L foot, shortened L
leg
Ext: no C/C/E
Update in Hospital Medicine 2013
Neuro:A&OX3
Labs: CPC, CMP, coags all normal except BS
159, Troponin < 0.04
EKG: Inferior Q waves seen on previous EKG, SR
L Hip x-ray: L non-displaced femoral neck
fracture
Hospital Course: The patient is admitted to you
and you consult ortho. You let ortho and
anesthesia know that she is a low to moderate
risk for peri-operative cardiac complications
and to proceed with surgery without further
testing.
Update in Hospital Medicine 2013
What is your plan for post operative
cardiac surveillance?
A.
B.
C.
D.
None
Telemetry monitoring
Telemetry monitoring and serial
troponins
Consult cardiology, they will know
what to do
Update in Hospital Medicine 2013
Case control (2:1), retrospective study, 1,212
hip fx patient cohort, median age 85
 169 with MI (14%), 92% in <48 hr post-op, 75%
“silent”
 Mortality MI vs no-MI
› In hospital 14.5% vs 1.2%
› 30 day 17.4% vs 4.2%
› 1 year 39.5% vs 23%
Limitations: 1998-02, limited use of b-blocker,
statin and ACE-I
 Conclusion – consider cardiac surveillance in
elderly hip fx patients
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Update in Hospital Medicine 2013
Describe risk factors for unplanned ICU transfer
within 24 hours of ward arrival from the ED
 178,315 ED to floor admissions
 At risk for ICU transfer <24 hr:
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PN (OR 1.5, CI 1.2 – 1.9)
MI (1.5, 1.2 – 2.0)
Sepsis (2.5, 1.9 – 3.3)
COPD (1.4, 1.1-1.9)
Night admissions, male sex
Decreased odds - high volume ED, admissions to
monitored transitional care
 Conclusion – Respiratory conditions, MI and
Sepsis should be triaged objectively out of the ED
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Update in Hospital Medicine 2013
 Medical
specialty societies were
asked to “choose wisely” and identify
five tests or procedures commonly
used in their field, whose necessity
should be questioned and discussed
 Sponsorship - ABIM Foundation
 Partnership with Consumer Reports to
develop and disseminate patientfriendly materials
Update in Hospital Medicine 2013
 Aims
- promote conversations
between physicians and patients by
helping patients choose care that is:
› Supported by evidence
› Not duplicative of other tests or
procedures already received
› Free from harm
› Truly necessary
Update in Hospital Medicine 2013
 Don’t
place, or leave in place, urinary
catheters for incontinence or
convenience or monitoring of output
for non-critically ill patients
(acceptable indications: critical illness,
obstruction, hospice, perioperatively
for <2 days for urologic procedures;
use weights instead to monitor
diuresis).
Update in Hospital Medicine 2013
 Don’t
prescribe medications for stress
ulcer prophylaxis to medical inpatients
unless at high risk for GI complications.
 Avoid transfusions of red blood cells
for arbitrary hemoglobin or hematocrit
thresholds and in the absence of
symptoms of active coronary disease,
heart failure or stroke.
Update in Hospital Medicine 2013
 Don’t
order continuous telemetry
monitoring outside of the ICU without
using a protocol that governs
continuation.
 Don’t perform repetitive CBC and
chemistry testing in the face of clinical
and lab stability.
Update in Hospital Medicine 2013
In UGIB use a transfusion threshold in
most patients of 7 mg/dl
 Consider resuming appropriate
anticoagulation at 4 days for your
patients with GI bleeds
 Use heparin bridging only in high risk
patients and only at 48 hours post-op
 Avoid dual antiplatelet therapy for stroke
prophylaxis
 Consider a shorter 5 day course of
prednisone for AE-COPD
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Update in Hospital Medicine 2013
Know the precautions associated with
quinolones including dysglycemia in diabetic
patients and peripheral neuropathy
 Consider monitoring for post-op cardiac
ischemia in elderly hip fracture patients
 Consider establishing objective criteria in your
hospital for ICU admissions for cardiac and
respiratory conditions, and for sepsis
 Use Choosing Wisely for quality improvement
projects in your hospital
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Update in Hospital Medicine 2013
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Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ;American
College of Chest Physicians Antithrombotic Therapy and Preventionof Thrombosis
Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis,
9th ed: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012;141:7S-47S
Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, et al;
Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a
clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49-58
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM,
et al; Endocrine Society. Management of hyperglycemia in hospitalized patients in
non-critical care setting: an endocrine society clinical practice guideline. J Clin
Endocrinol Metab. 2012;97:16-38
Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE Jr, et al; 2012
Writing Committee Members. 2012 ACCF/AHA focused update of the guideline for
the management of patients with unstable angina/non-St elevation myocardial
infarction : a report of the American College of Cardiology Foundation/ American
Heart Association Task Force on practice guidelines. Circulation. 2012;126:875-910
Dellinger, RP, et at. Surviving Sepsis Campaign Guidelines Committee including
the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for
management of severe sepsis and septic shock: 2012. Crit Care Med. 2013
Feb;41(2):580-637
Update in Hospital Medicine 2013
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Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil
C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C,
SantalóM, Muñiz E, Guarner C. Transfusion strategies for acute upper
gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11-21.
Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent
hemorrhage, and death after warfarin therapy interruption for
gastrointestinal tract bleeding. Arch Intern Med. 2012;172:1484-91
Tafur AJ, McBane R 2nd, Wysokinski WE, et al. Predictors of major bleeding in
peri-procedural anticoagulation management. J Thromb Haemost.
2012;10:261-7.
Meng Lee, MD; Jeffrey L. Saver, MD; Keun-Sik Hong, MD, PhD; Neal M. Rao,
MD; Yi-Ling Wu, MS; and Bruce Ovbiagele, MD, MS Risk–Benefit Profile of
Long-Term Dual- Versus Single-Antiplatelet Therapy Among Patients With
Ischemic Stroke A Systematic Review and Meta-analysis Ann Intern Med.
2013;159:463-470.
Chou HW, Wang JL, Chang CH, et al Risk of severe dysglycemia among
diabetic patients receiving levofloxacin, ciprofloxacin, or moxifloxacin in
Taiwan Clin Infect Dis. 2013 Published on line Aug 15, 2013
Update in Hospital Medicine 2013
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US Food and Drug Administration. FDA Drug Safety Communication: FDA
requires label changes to warn of risk for possibly permanent nerve damage
from antibacterial fluoroquinolone drugs taken by mouth or by injection.
http://www.fda.gov/downloads/Drugs/DrugSafety/UCM365078.pdf
Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional
glucocorticoid therapy in acute exacerbations of chronic obstructive
pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA.
2013;390(21):2223-2231
Gupta BP, Huddleston JM, Kirkland LL, et al. Clinical presentation and
outcome of perioperative myocardial infarction in the very elderly following
hip fracture surgery. J Hosp Med. 2012;7:713-6.
Delgado MK, Liu V, Pines JM, et al. Risk factors for unplanned transfer to
intensive care within 24 hours of admission from the emergency department
in an integrated healthcare system. J Hosp Med. 2013;8:13-9
Choosing Wisely, Society of Hospital Medicine – Adult Hospital Medicine, Five
Things Physicians and Patients Should Question
http://www.choosingwisely.org/doctor-patient-lists/society-of-hospitalmedicine-adult-hospital-medicine/
Update in Hospital Medicine 2013
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I WISH!
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None
QUESTIONS?
Update in Hospital Medicine 2013