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Cool Tools In Hospital Medicine. Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University of Oklahoma School of Community Medicine, Tulsa. Updates in Hospital Medicine from 2013 Don’t get left behind….
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Cool Tools In Hospital Medicine Jabraan Pasha, M.D. Assistant Professor of Medicine Associate Program Director, Internal Medicine Residency University of Oklahoma School of Community Medicine, Tulsa
Financial Disclosures • NONE
Medicine is ever-changing Stay updated. Don’t get left behind!
Objectives Review 3 articles from the past year that have the potential to change some of our clinical practices.
Updates in Hospital Medicine Case 1: 68-yo male with a h/o alcoholic cirrhosis presents with 2-day h/o hematemesis and melena. Last episode of hematemesis was during the encounter, on your shoes. Current vitals are: T 36.8, P 93, RR 16, BP 108/47.
Updates in Hospital Medicine Case 1: PE significant for mild scleral icterus, 2/6 systolic murmur, and non-tender Abd with positive fluid wave. Patient’s Hgb in ED found to be 7.5 g/dLHgb, last week in clinic was 12.7 g/dL.
Updates in Hospital Medicine What would you do regarding the patient’s anemia? • Anticipating a continued decrease in Hgb, transfuse 2 units PRBCs targeting a Hgb of 9g/dL • Anticipating a continued decrease in Hgb, transfuse 1 unit PRBCs now • Recheck Hgb Q4hrs and transfuse if Hgb <7 g/dL • Target Hgb of 9 g/L?! Lets see if we can get him to 20!
Updates in Hospital Medicine • Patient selection • Patients 18 yrs or older with hematemesis, gastroccult positive aspirate, or melena witnessed by hospital staff were available for inclusion. • Patients with lower GI bleed, massive exsanguinating hemorrhage, low risk of re-bleed, and recent transfusion were all excluded.
Updates in Hospital Medicine • Study design • 921 patients with severe upper gastrointestinal bleed • 461 assigned to restrictive strategy (transfuse when Hgb <7 g/dL) • 460 assigned to liberal strategy (transfuse when Hgb <9g/dL)
Updates in Hospital Medicine • Outcome Measures • Primary: Rate of death of any cause within the first 45 days. • Secondary: Rate of further bleeding and the rate of in-hospital complications.
Updates in Hospital Medicine Results: Red-cell transfusion
Updates in Hospital Medicine Results: Death by 6 weeks
Updates in Hospital Medicine • Results: Death from any cause in 45 days
Updates in Hospital Medicine • Results: Further Bleeding
Updates in Hospital Medicine Results: Days in hospital
Updates in Hospital Medicine Results: Adverse Effects
Updates in Hospital Medicine • Limitations • Results cannot be generalized to all UGIB patients • Study was unable to be blinded
Updates in Hospital Medicine • Case 2 71-yo male with h/o Ischemic HF, last EF 35% 2 mo ago, here with gradual increase in weight gain, dyspnea and LE edema.
Updates in Hospital Medicine • Case 2 Vitals: T 36.8, P 87, RR 22, BP 137/56 PE significant for crackles BL on lung auscultation and 3+ LE edema. BNP elevated at 506. CXR shows moderate pulmonary edema.
Updates in Hospital Medicine In addition to diuresis, what would you do? • Place order for 2000ml fluid restriction and sodium restrict to 1gm. • Place an order for sodium restriction to 2gm. • Place order for 800ml fluid restriction and sodium restrict to 800mg. • Allow patient to drink to thirst and order heart healthy diet without sodium restriction.
Updates in Hospital Medicine • Patient Selection • Adult patients with ADHF and EF <45%, Boston criteria score >8 and length of stay no more than 36 hours were included in the study. • Patients with CrCl < 30mL/min, cardiogenic shock or survival compromised by other underlying illness were excluded.
Updates in Hospital Medicine • Study design • Intervention group received and fluid restriction of 800 mL/d and sodium restriction of 800 mg/d. N=38 • Control group received a standard hospital diet and liberal fluid (at least 2.5 L) and sodium (3-5 g). N=37
Updates in Hospital Medicine • Study Outcomes • Primary End Point: Weight loss and clinical stability at 3-day assessment. • Secondary End Points: Perceived thirst and hospital readmission for HF within 30 days of hospital discharge.
Updates in Hospital Medicine Result: Change in Weight
Updates in Hospital Medicine Result: Clinical congestion Score
Updates in Hospital Medicine Result: Thirst
Updates in Hospital Medicine Hospital readmission and ED visits
Updates in Hospital Medicine Result: Change in lab values
Updates in Hospital Medicine Result:
Updates in Hospital Medicine • Limitations • Subjective way of measuring perceived thirst
Updates in Hospital Medicine • Case 3 • 69-yo F with h/o CAD, ESRD with chief complaint of LE pain and redness for 3 days. Admits to fever of 38.3 at home. Denies any discharge.
Updates in Hospital Medicine • Case 3 • Vitals reveal T – 38.1, P – 96, BP 147/82 RR – 14 PE – Redness of LLE. Tenderness to palpation, no fluctuance palpated.
Updates in Hospital Medicine • Case 3
Updates in Hospital Medicine What antibiotic regimen would you choose for your patient? • Vancomycin 15mg/kg IV Q12 with Zosyn 3.375 Q6hrs • Vancomycin 15mg/kg BID • Linezolid 600mg IV Q12 • Cefazolin 1g IV Q8 • Order vanc, zosyn, levaquin and fluconazole with a side of flagyl for the C.diff we have given to the patient
Updates in Hospital Medicine • Study Participants • Patients >12 mo old with non-purulent cellulitis were included in the study. • Exclusion criteria: severe penicillin allergy, sulfa allergy, admission to hospital, immunocompromised state, facial cellulitis and several other factors.
Updates in Hospital Medicine • Study design • 73 pts received treatment doses of cephalexin and trimethoprim-sulfamethoxazole for 7-14 days depending on subjective resolution. • 75 pts received treatment doses of cephalexin + placebo for 7-14 days depending on subjective resolution.
