cool tools in hospital medicine

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 from2013

Don’t get left behind…

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Looking back…

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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.


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/dL Hgb, last week in clinic was 12.7 g/dL.


What would you do regarding the patient’s anemia?

a. Anticipating a continued decrease in Hgb, transfuse 2 units PRBCs targeting a Hgb of 9g/dL

b. Anticipating a continued decrease in Hgb, transfuse 1 unit PRBCs now

c. Recheck Hgb Q4hrs and transfuse if Hgb <7 g/dL

d. Target Hgb of 9 g/L?! Lets see if we can get him to 20!


Patient selectionPatients 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.


Study design921 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)


Outcome MeasuresPrimary: Rate of death of any cause

within the first 45 days.

Secondary: Rate of further bleeding and the rate of in-hospital complications.


Results: Red-cell transfusion

Intervention Restrictive group Liberal group

Any transfusion 219 (49) 384 (86)

Total 671 1638

Mean/patient 1.5 3.7


Results: Death by 6 weeks

Diagnosis Restrictive group

Liberal group P Value

Overall 23/444 (5) 41/445 (9) 0.02

Cirrhosis 15/139 (11) 25/138 (18) 0.08

Child-Pugh A/B 5/113 (4) 13/109 (12) 0.02

Child-Pugh C 10/26 (38) 12/29 (41) 0.91

Varices 10/93 (11) 17/97 (18) 0.18

Peptic ulcer 7/228 (3) 11/209 (5) 0.26


Results: Death from any cause in 45 days

Restrictive group

Liberal group Hazard ratio P value

23(5) 41(9) 0.55(0.33-92) 0.02


Results: Further Bleeding

Diagnosis Restrictive group

Liberal group

Hazard ratio

P Value

Overall 45/444(10) 71/445(16) 0.62 (0.33-0.92)

0.01

Cirrhosis 16/139(12) 31/138(22) 0.49(0.27-0.9)

0.02

PUD 23/228(10) 33/209(166) 0.63 (0.37-1.07)

0.09


Results: Days in hospital

Restrictive group Liberal group P Value

9.6 11.5 0.01


Results: Adverse Effects

Complication Restrictive group

Liberal group P Value

Any 179(40) 214(48) 0.02

Transfusion reactions

14(3) 38(9) 0.001

Cardiac complications

49(11) 70(16) 0.04

CVA 3(1) 6(1) 0.33

Bacterial infection

119(27) 135(30) 0.41


Limitations

Results cannot be generalized to all UGIB patients

Study was unable to be blinded


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.


Case 2Vitals: 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.


In addition to diuresis, what would you do?

a. Place order for 2000ml fluid restriction and sodium restrict to 1gm.

b. Place an order for sodium restriction to 2gm.

c. Place order for 800ml fluid restriction and sodium restrict to 800mg.

d. Allow patient to drink to thirst and order heart healthy diet without sodium restriction.

JAMA Internal Medicine 2013


Patient SelectionAdult 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.


Study designIntervention 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


Study OutcomesPrimary 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.


Result: Change in Weight


Result: Clinical congestion Score


Result: Thirst


Hospital readmission and ED visits

Intervention group Control group P Value

11(29) 7(19) 0.41


Result: Change in lab values


Result:


LimitationsSubjective way of measuring perceived thirst


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.


Case 3 Vitals reveal T – 38.1, P – 96, BP

147/82

RR – 14

PE – Redness of LLE. Tenderness to palpation, no fluctuance palpated.


Case 3


What antibiotic regimen would you choose for your patient?

a. Vancomycin 15mg/kg IV Q12 with Zosyn 3.375 Q6hrs

b. Vancomycin 15mg/kg BID

c. Linezolid 600mg IV Q12

d. Cefazolin 1g IV Q8

e. Order vanc, zosyn, levaquin and fluconazole with a side of flagyl for the C.diff we have given to the patient

Clinical infectious disease 2013


Study ParticipantsPatients >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.


Study design73 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.


Outcome measuresPrimary Outcome: Risk difference for

cure in the intent-to-treat group

Secondary Outcome: Association of nasal MRSA colonization and with treatment response


Results: Cure

Bactrim (73) Placebo (73) P Value

62(85) 60(82) 0.66


Results: Progression to abscess


5(6.8) 5(6.8) 1.0


Results: Adverse events


36(49) 39(53) 0.62


Limitations No objective way to make etiologic diagnosis

Patients with cellulitis complicating lymphedema were not studied

Diabetic patients were excluded

Hospitalized patients were excluded


Summary Transfusion for Hgb <7g/dL may be appropriate for UGIB


SummaryTransfusion for Hgb <7g/dL may be

appropriate for UGIB

Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation


Sources Pallin, D. J., W. D. Binder, M. B. Allen, M. Lederman, S. Parmar, M. R. Filbin, D. C. Hooper, and C. A. Camargo. "Clinical Trial: Comparative

Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial." Clinical Infectious Diseases 56.12 (2013): 1754-762. Web.

Villanueva, Càndid, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi, Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, and Carlos Guarner. "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding." New England Journal of Medicine 368.1 (2013): 11-21.

Leuppi, Jörg D., Philipp Schuetz, Roland Bingisser, Michael Bodmer, Matthias Briel, Tilman Drescher, Ursula Duerring, Christoph Henzen, Yolanda Leibbrandt, Sabrina Maier, David Miedinger, Beat Müller, Andreas Scherr, Christian Schindler, Rolf Stoeckli, Sebastien Viatte, Christophe Von Garnier, Michael Tamm, and Jonas Rutishauser. "Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease." Jama 309.21 (2013): 2223.

Aliti, Graziella Badin, Eneida R. Rabelo, Nadine Clausell, Luís E. Rohde, Andreia Biolo, and Luis Beck-Da-Silva. "Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure." JAMA Internal Medicine 173.12 (2013): 1058.

Duodenal Infusion of Feces for Recurrent." New England Journal of Medicine 368.22 (2013): 2143-145


Summary Transfusion for Hgb <7g/dL may be appropriate for UGIB

Question the benefit of Fluid and sodium restriction in patients admitted for CHF exacerbation

Is MRSA coverage needed for uncomplicated cellulitis?


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