to treat or not to treat: isn’t that always the question?...– bp 146/92 – rr 16 – spo2 90%...

4/10/2012

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This information is the property of Jennifer Sherman, PT and should not be copied or otherwise used without expressed written permission of the author

To treat or not to treat: Isn’t that always the question?

A look at clinical decision making in the acute care environment

MN-APTA Spring Conference 2012Jennifer Sherman, PT, DPT

Sister Kenny Rehabilitation Institute at United Hospital1

Objectives

At the end of this course, participants will be able to:• Identify areas in acute care practice where there is

current evidence to support treatment decisions• Discuss some common absolute and relative

contraindications to physical therapy intervention in the acute care setting

• Recall data sources (i.e. lab values, EKG, patient examination, vitals, etc.) that may be available to the acute care therapist and demonstrate ability to synthesize this data in order to form a clinical judgment

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Inspiration…

• Costello E, Elrod C, Tepper S. Clinical decision making in the acute care environment: A survey of practicing clinicians. JACPT. 2011;2:46-54.

• Study Purpose: Look at current practice trends in acute care using a case-based clinical decision making survey

• Subjects: Acute and Cardiovascular Pulmonary section members

• Methods: Chose between “treat” or “not to treat” based on 8 clinical vignettes

• Responses analyzed by educational training and years of experience

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Case 1Findings POD #2:� +Tenderness in calf region� Well’s clinical decision rule is >2

� Doppler + for proximal DVT� She is given Lovenox (1.5 mg/kg

SC 1x/day) and and has on thigh length compression stockings.

� In the pm: she is to be “out of bed and ambulating with a walker”

� Treat or not? Why?

72 year old Caucasian female

•Walked 1 mile/day pre-op

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What are the facts?

• Common symptoms of DVT:– swelling, pain, warmth, and discoloration in the

involved extremity• Accurate diagnosis is essential!

– High risk for serious disease with proximal DVT that is not treated

– Potential risk of anti-coagulating a patient who does not have a DVT

• In up to 40-50% of those with proximal DVT, silent PE has already occurred by the time that the patient is seen

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Well’s Clinical Prediction Rule for DVT

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Clinical feature Score

Active Cancer (treatment ongoing or within the last 6 months or palliative)

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Paralysis, paresis, or recent plaster immobilization of the lower extremities

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Recently bedridden for more than 3 days or major surgery, within past 4 weeks

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Localized tenderness along the distribution of the deep venous system 1

Calf swelling by more than 3 cm when compared to the asymptomatic leg (measured below tibial tuberosity)

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Pitting edema (greater in the symptomatic leg) 1

Collateral superficial veins (nonvaricose) 1

Alternative diagnosis as likely or more like that that of DVT -2

Well’s Clinical Prediction Rule for DVT

Adapted from Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795 and Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35.

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Scoring

High probability 3 or greater

Moderate probability 1 or 2

Low probability 0 or less

If history of previous DVT: Add 1 to score

DVT likely 2 or greater

DVT unlikely 1 or less

Testing for DVT

• D-Dimer (lab test)– a degradation product of cross-linked fibrin– detectable at levels >500 ng/mL of fibrinogen

equivalent units in nearly all patients with venous thromboembolism (VTE)

– commonly present in hospitalized patients, particularly the elderly, those with malignancy, recent surgery, and many other conditions, including the second and third trimester of a normal pregnancy

– So it’s sensitive, but not as specific to VTE

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Testing for DVT

• Contrast venography– Gold standard– X-ray with constant

infusion of dye into veins

– not recommended as an initial screening due to patient discomfort, exposure to dye and radiation, and $$$

• Compression ultrasonography– Abnormal

compressibility of the vein or Abnormal Doppler color flow = DVT

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Treatment of DVT• Unfractionated heparin

– Unpredictable– Administered by IV– Monitored by activated

partial thromboplastin time (aPTT) or heparin levels, and then titrated

– Target aPTT in the range of 1.5 to 2.5 times the patient's aPTT baseline value

– corresponds to a heparin blood level of 0.3 to 0.7 units/mL by the amidolytic anti-factor Xa assay

• Low Molecular Weight Heparins (LMWH)– Lovenox, Fragmin– Injected, allows for OP

treatment– Allows for a fixed dose– Very reliable—no labs

needed– Duration of the

anticoagulant effect is greater

– Peak effect• 3 to 5 hours following

subcutaneous injection 10

Treatment of DVT

• Warfarin (Coumadin)– Oral– Overlaps the initial

heparin product the first few days

– Monitored by International Normalized Ratio (INR) with goal range of 2.0-3.0

– Requires frequent monitoring

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What’s the history? What’s the evidence?

• Old adage: DVT = Don’t touch them!!• Today’s evidence:

– “In patients with acute DVT, we suggest early ambulation over initial bed rest.”

– Early ambulation was “not associated with a higher risk of progression of DVT, new PE or death”, “safe”, and “clinicians should be confident in prescribing ambulation in this population”

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Recommendation: Treat.

� Current evidence supports “to treat” as she is being medically managed with Lovenox and compression stockings and is safe to participate in mobilization activities

• Almost 40% of survey respondents chose to not treat due to:◦ Timeframe regarding anticoagulation

◦ Peak for Lovenox is 3-5 hours after administration◦ Need to check labs prior (PT, aPTT, INR)

� These tests are insensitive measures of Lovenox◦ Decision making most likely more due to institutional

guidelines or not taking into account the anticoagulant being used 13

Case 2– Resting HR = 86 bpm with

normal sinus rhythm (2-3 PVCs/min)

– BP 146/92

– RR 16– SpO2 90% on room air– Patient with c/o mild chest

discomfort radiating into left arm with ST level depression on EKG by 1 mm

– You are to begin Phase 1 cardiac rehab

Treat or Not? Why?

62 year old African American obese man (BMI 31)

•History of HTN and high cholesterol

•Day 1 post MI•Current meds during hospitalization:

•Inderol•Ticlid•Lipitor

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What information do we have?• Normal values (adults on no antihypertensive

medications and who are not acutely ill)– BP

• Normal: <120 SBP <80 dBP• PreHTN: 120-139 80-89• Stage 1 HTN: 140-159 90-99• Stage 2 HTN: >159 >99

– HR (at rest): 50-100 bpm– RR ( at rest): 12-20 breaths/minute– SpO2 (O2 sats): >95%

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ACC/AHA Guidelines for Exercise Testing

Absolute contraindications:• Acute myocardial infarction (within 2 d)• Unstable angina not previously stabilized by

medical therapy• Uncontrolled cardiac arrhythmias causing

symptoms or hemodynamic compromise• Symptomatic severe aortic stenosis• Uncontrolled symptomatic heart failure• Acute pulmonary embolus or pulmonary infarction• Acute myocarditis or pericarditis• Acute aortic dissection

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ACC/AHA Guidelines for Exercise Testing

Relative Contraindications• Left main coronary stenosis• Moderate stenotic valvular heart disease• Electrolyte abnormalities• Severe arterial hypertension (SBP>200, DBP>110)

• Tachyarrhythmias or bradyarrhythmias• Hypertrophic cardiomyopathy and other forms of

outflow tract obstruction• Mental or physical impairment leading to inability

to exercise adequately• High-degree atrioventricular block

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ECG Review

18http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson1/index.html. Accessed 3/18/2012.

EKG Review

• Step 1: Locate the P wave – Absence of P waves may occur secondary to

atrial fibrillation– Check the rate

• Bradycardia is < 60• Tachycardia is >100

• Step 2: Establish the relationship between P waves and the QRS complex– i.e. 1:1 ratio?

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EKG Review

• Step 3: Analyze the QRS• Step 4: Check regularity

– Is it regularly irregular or irregularly irregular?

• Step 5: Correlate with the clinic picture

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Atrial fibrillation

• Caused by a loss in atrial contraction due to multiple ectopic foci & can lead to emboli

• P-wave not seen, wavy baseline is seen instead. • Irregularly irregular ventricular response• Patient may have symptoms of lowered CO or

hemodynamic instability especially with rapid ventricular response– Palpitations, Dyspnea, Chest pain, Hypotension,

Lightheadedness, presyncope or syncope

• Will feel irregularly irregular on palpation

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Premature Ventricular Contraction (PVC)

Rate-�variableP wave-�usually obscured by the QRS, PST or T wave of the PVCQRS-�wide > 0.12 seconds; morphology is bizarre with the ST segment and the T wave opposite in polarityRhythm-�irregular. PVC's may occur in singles, couplets or triplets; or in bigeminy, trigeminy or quadrigeminy.

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ECG with ischemia or infarct

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With ischemia and infarction, most common are ST

segment changes (e.g. depression or elevation)

associated with T wave flattening or inversion

Normal

T wave change & start of ST elevation

ST elevation with ongoing T wave change

Pathological Q wave forms, less ST elevation, T wave inversion

Q wave, T wave inversion

Q wave, upright T wave

http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson9/index.html. Accessed 3/18/2012.

Recommendation: Do not treat.

• Patient is presenting with sign and symptoms of myocardial ischemia or “unstable angina”– Chest discomfort into left arm and ST

depression– Unstable angina is an absolute

contraindication for initiating an exercise test or aerobic activities per AACVPR and ACSM

– 82% correct responses on survey

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Case 3• Swan Ganz catheter reading

pulmonary capillary wedge pressure of 18-24mm Hg

• Patient c/o:

– dyspnea when reclined– 3+ pedal edema– B swollen jugular veins

– SpO2 88% on 2L with crackles audible over lower 50% of lungs

• Labs + for significant rise in CK-MB and troponins

66 year old male • post Q wave MI• 24 hour delay in

admission

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What do we know?

• Non-invasive lines– ECG– Pulse Oximetry

• Invasive lines– Arterial line (a-line, art-line)– Central venous pressure (CVP)

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More invasive lines

• Pulmonary Artery Catheter (Swan Ganz)

• Intraaortic Balloon Pump

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More invasive lines

• Chest tubes

• Intracranial pressure monitoring– Ventriculostomy, lumbar drain

• Mechanical Ventilation

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Cardiac Labs

• Troponins– Proteins associated with cardiac muscle– Released into blood after myocardial injury or

infarction• Creatnine Kinase-Myoglobin (CK-MB)

– Released after cell death• Brain natriuretic peptide (BNP)

– Hormone released primarily from the heart, particularly the ventricles

– Most patients with HF and dyspnea have values above 400 pg/mL

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Heart Failure

• Commonly the result of Cardiac Muscle Dysfunction (CMD)

• http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=563

• CHF symptoms are a:– “sequence of events

with a resultant increase in fluid in interstitial spaces of the lungs, liver, subcutaneous tissues, and serous cavities”

• Causes of CMD and CHF: – HTN– CAD/MI– Cardiac dysrhythmias– Renal insufficiency– Cardiomyopathy– Heart valve

abnormalities– Pericardial effusion– PE/Pulmonary HTN– SCI– Age-related changes

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Heart Failure Descriptions• Right sided

– RV fails to pump effectively with back up into periphery

• Left sided

– LV fails to pump effectively with back up in to lungs

• Biventricular

– LV fails�back up into lungs�PA pressures rise�increased RV resistance causing it to fail too

• Low output

– Low CO at rest and with exertion

• High output – Results from fluid overload on

heart with decreased contractility

• Systolic– Impaired contractility of

ventricles = low stroke volume and low Ejection Fraction (EF)

• Diastolic– Inability of ventricles to accept

blood from atria at rest or with activity

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Heart Failure

Symptoms• Dyspnea

– Increased RR and/or tidal volume

• Paroxysmal Nocturnal Dyspnea– Due to supine position

• Orthopnea

– Dyspnea in recumbent position

• Fatigue

Signs• Weight Gain• Peripheral edema• Hepatomegaly• Jugular Vein Distension• Crackles/Rales • Abnormal heart sounds

on auscultation• Sinus tachycardia• Decreased exercise

tolerance

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33Collins SM, Cahalin LP. Acute Care Physical Therapy in Patients with Heart Failure. Acute Care Perspectives. 2005;14(3): 18. (With permission)

Acute Care PT Examination

in patients with CHF:

Guiding Questions

Recommendation: Do not treat

• Labs indicate active MI• Classic signs and symptoms of

“uncontrolled/decompensated CHF”

• 90% correct on survey

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Case 4� 2 days post R BKA

�He has just given himself an insulin injection with current blood glucose of 82 mg/dL

�Resting HR 114 bpm

�He is confused and anxious

What to do?

46 year old obese manBMI 38 Waist 43”History of DM II

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Medication management of type 2 DM

• Metformin– recommended at the

time of diagnosis– May not be

appropriate in those with impaired renal function, liver disease, heart failure, history of lactic acidosis, or decreased tissue perfusion

– Less hypoglycemia than other meds

Insulin secretagogues• Sulfonylureas

– Glipizide (Glucotrol) and others

– Effectiveness decreases over time

– Higher risk of hypoglycemia

• Repaglinide (Prandin)– Can be used in patient

with chronic kidney disease

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Medication management-Insulin

• Rapid acting– Humalog– Novolog– Apidra

• Short acting– humulin or novolin

• Intermediate acting– NPH– Lente

• Long acting• Ultralente• Lantus• Levemir or detemir

– Pre-mixed (2x/day)• Humulin 70/30• Novolin 70/30• Novolog 70/30• Humulin 50/50• Humalog mix 75/25

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What does the evidence tell us about exercise in persons with diabetes?

• Exercise results in improved glycemic control independent of weight loss

• Higher levels of aerobic fitness are associated with lower mortality no matter a person’s weight

• A single bout of aerobic exercise alters insulin sensitivity for 24-72 hours

• Resistance training has been found to be safe and beneficial

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Exercise when glycemic control is suboptimal

• Hyperglycemia– Light or moderate

exercise should help ↓plasma glucose levels

– Make sure patient is adequately hydrated and ketones are negative

• Hypoglycemia– Rare in those not

treated with insulin or insulin secretagogue

– ADA suggests carb be ingested prior to exercise if glucose levels are <100 mg/dL for those on insulin or insulin secretagogue

– Beta blockers can blunt the symptoms

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�Classic symptoms of hypoglycemia◦ High resting HR◦ Anxiety◦ Confusion

�Almost 40% opted to treat on survey with caveat of “close monitoring” or “low level bedside activity”

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Case 5

• Lab values:– WBC = 2,200– Hgb = 7.4

– HCT 21%– Platelets = 3,200

• Vitals:

– Resting HR = 114 bpm– BP 114/64– SpO2 92% on room air

– Respiratory rate = 16

• 58 year old female• Receiving bone

marrow transplant following diagnosis of leukemia

• Prior to transplant, immunosuppression has been induced trying to kill off neoplastic cells in her blood and marrow

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Acute Care Section-APTALab Values Resource Update 2012• “It is the professional responsibility of the

physical therapist to interpret available laboratory values as a component of the examination and evaluation of a patient/client, to suggest laboratory testing when indicated, and to use lab values to guide the determination of safe and effective interventions for the patient/client.”

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Acute Care Section-APTALab Values Resource Update

2012• “We, as physical

therapists, act as consultants in the rendering of our professional opinion and bear the responsibility to advise the referring practitioner about the indications for physical therapy intervention.”

• http://www.acutept.org/associations/11622/files/LabValuesResourceUpdate2012.pdf

• Considerations when interpreting lab values as they pertain to PT interventions:– Acute vs Chronic– Risk vs Benefit

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Lab Value NormsHematocrit (Hct):

– % RBCs in blood– Adult male: 41-51%– Adult female: 36-47%

• Hemoglobin (Hgb)– Protein in RBCs that

allow for binding to O2– Adult male: 14-17

gm/DL– Adult female: 12-16

gm/DL

• White Blood Cells– # of WBCs– 3900-10,700 cells– Leukocytosis when

values are > 11,000– Neutropenia is when

ANC <1500• Platelets

– 150,000-450,000– Thrombocytopenia

• <10,000-15,000– Thrombocytosis

• >400,000

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Practice Guidelines

• <25%/<8 g/dL– Light ROM, isometrics.

Avoid aerobic or progressive programs

• 25-35%/8-10 g/dL– ADLs with assistance as

needed for safety, light aerobics, light weights (1-2#)

• >35%/>10 g/dL– Ambulation and self care

as tolerated, resistance exercises

• <10,000 and/or temp >100.5– Hold therapy

• 10,000-20,000– Exercise/bike without

resistance

• >20,000– Exercise/bike with or

without resistance

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• Hematocrit/Hemoglobin • Platelets

Recommendation: Treat

�Many of her labs are below levels often thought to be contraindications for activity�But,

◦ She’s young, not a fall risk, and receiving treatment that is causing these changes.

◦ Vitals were relatively normal◦ Treatment would be limited in physiologic cost (ie

bed activities) and patient would need to be monitored closely

�Survey says: 57% opted to treat

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Case 6• He is comfortable at rest• Complaints of “chest

tightness’’ with usual activity

• EKG shows 2 mm ST segment depression

• He appears pale

• 54 year old male

• 2 days post TKA

• Long history of HTN and CAD

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• Already has history of cardiovascular disease

• Signs of MI with activity: pallor, chest tightness, ST depression

• Risk of cardiac event outweighs the benefits of mobilization after arthroplasty

• 94% in survey opted to not treat

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Case 7� Goes into ventricular

tachycardia during activity• Terminate activity and notify

medical personnel

�Without EKG, this patient will demonstrate symptoms associated with lack of blood perfusion:◦ Chest pain◦ Palpitations◦ Anxiety◦ Diaphoresis◦ Syncope

◦ It is a pulseless rhythm so initiate code protocol

• 72 year old female

• POD #1 THA

• Known history of dysrhythmias

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Case 8• Vitals with activity:

� Sinus tachycardia (HR 110)� BP 132/70

� SpO2 94% on RA� RR 20

• Patient is day 2 post CABG

• Vitals at rest:� HR 94

� BP 114/64� SpO2 92% on

RA� RR 16

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Abnormal cardiovascular responses to activity

– SBP: rapid increase, blunted rise and NOT on beta blockers, any decrease

– DBP: >10 mm Hg rise– HR: rapid rise, blunted rise and NOT on

medications that alter HR, any decrease– SpO2: Decrease from baseline– EKG: Becomes irregular, more PVCs

than at resting

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Recommendation: Treat

◦ These vitals demonstrate normal physiologic response to activity

◦ HR increased by< 30 bpm as recommended for patients post-CABG

◦ 95% of respondents opted for “treat”

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More about the study…

• Limitations:– Survey constructed by

one author, not peer reviewed

– Cases were hypothetical and only a “snapshot” of info

– Low response rate– Possible bias with

those that did respond

• Outcomes:– 80% of survey

participants answered 5/8 in accord with the survey constructor

– N = 356– PTs with10+ years

experience coupled with advanced degrees had the highest scores

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In summary…

�We often need to educate other health care providers on our role as exercise and activity specialists◦ Understanding the existing evidence and

guidelines can help with this

�Medicine is changing all the time and therapy in the acute care environment is no exception

�Thanks for listening!!!

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References• Costello E, Elrod C, Tepper S. Clinical decision making in the acute care

environment: A survey of practicing clinicians. JACPT. 2011;2:46-54.

• Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795.

• Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35.

• Meignan M, Rosso J, Gauthier H, et al. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med. 2000;160(2):159.

• Huisman MV, Büller HR, ten Cate JW , et al. Unexpected high prevalence of silent pulmonary embolism in patients with deep venous thrombosis. Chest. 1989;95(3):498.

• Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med. 1998;129(12):1044.

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References• Birdwell BG, Raskob GE, Whitsett TL , et al. The clinical validity of normal

compression ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med. 1998;128(1):1.

• Hull RD, Raskob GE, Rosenbloom D , et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med. 1992;152(8):1589.

• Eikelboom JW, Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antiplatelet Drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Chest. 2012 Feb;141(2 Suppl):e89S-e119S.

• Aissaoui N, Martins E, Mouly S, Weber S, Meune C. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009 Sep 11;137(1):37-41. Epub 2008 Aug 8.

• Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res. 2008;122(6):763-73. Epub 2007 Dec 21.

• Anderson CM, Overend TJ, Godwin J, Sealy C, Sunderji A. Ambulation after deep vein thrombosis: a systematic review. Physiother Can. 2009 Summer;61(3):133-40. Epub 2009 Jul 16.

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References

• Hillegass E. Essentials of Cardiopulmonary Physical Therapy, 3rd

ed. Saunders(2010).

• Gibbons RJ, Balady GJ, Bricker JT et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883

• ACC/AHA Guidelines for Exercise Testing: Executive Summary A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation. 1997; 96: 345-354.

• Podrid PJ. ECG tutorial: Basic principles of ECG analysis. Uptodate.com. Last updated: 4/17/2011. Accessed 3/18/2012.

• Malone DJ. Physical Therapy in Acute Care: A Clinician’s Guide. Slack (2006).

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References• Harris KB. Critical Care Competency Program Development and

Implementation. Acute Care Perspectives.2006(15).1:16-19.• Collins SM, Cahalin LP. Acute Care Physical Therapy in Patients with

Heart Failure. Acute Care Perspectives. 2005;14(3): 18.• Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD.

Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Jun;29(6):1433-8.

• Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B; American Diabetes Association; European Association for Study of Diabetes. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009 Jan;32(1):193-203. Epub 2008 Oct 22.

• Types of Insulin for Diabetes Treatment. http://diabetes.webmd.com/diabetes-types-insulin. Accessed 3/20/2012

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References

• Acute Care Section‐APTA Task Force on Lab Values. http://www.acutept.org/associations/11622/files/LabValuesResourceUpdate2012.pdf. Accessed 3/21/2012.

• Baumann FT, Zopf EM, Nykamp E, Kraut L, Schüle K, Elter T, Fauser AA, Bloch W. Physical activity for patients undergoing an allogeneic hematopoietic stem cell transplantation: benefits of a moderate exercise intervention. Eur J Haematol. 2011 Aug;87(2):148-56.

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to treat or not to treat: isn’t that always the question?...– bp 146/92 – rr 16 – spo2 90%...

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