Sunday, January 01, 2012

A look back at 2011---was there any practice changing evidence for hospitalists?

I've been looking back over my posts for the year 2011. There was a lot of published research over the past year that should be of interest to hospitalists but I found little that was revolutionary, what I would call game changing. There were some articles with practice changing potential, either because of new information or reminders of under-appreciated clinical points, which I have linked below.

GI bleeding prophylaxis (PPIs and H2 blockers) is over-utilized in hospitalized patients. This is driven by performance incentives and, probably, the EMR.

CT angiography is not the diagnostic modality of choice for PE. Not new but certainly under-appreciated.

New guidelines clarify glycemic control in hospitalized patients. The long and the short: intensive glycemic control is not recommended for hospitalized patients with the exception of post surgical patients in the ICU. This is based on the best evidence we currently have. Not new, but contrary to the prevailing dogma.

Long term PPI use and hypomagnesemia. Hypomagnesemia may have consequences for hospitalized patients. If your patient has been taking a PPI it may be worth checking a magnesium.

Hyperammonemia---not just in cirrhotics anymore. Nonhepatic hyperammonemia is an emerging entity which has several causes. Consider ordering a blood ammonia in patients with altered mental status even in the absence of liver disease.

Surgical risk in patients with liver disease. Not new, but under-emphasized. Although patients with heart disease do not generally need to be cleared for elective surgery patients with liver disease often do. Know the contraindications.

Don't bother with the AED. It may be great at the mall or the airport but is associated with worse outcomes when patients arrest in the hospital according to a study this year.

Nesiritide---neither beneficial nor harmful in terms of important outcomes. Debate settled. The only remaining question is what is its niche if it even has one.

Outpatient management of low risk PE patients. Not considered standard of care but safe according to a Lancet study this year.

ABCD 2 score for patients with TIA---too good to be true. The sensitivity and specificity depend on what cut off you use for the score. In order to make it sensitive enough you lose specificity and end up admitting just about everyone. The easy-to-use clinical tool, very popular among emergency medicine types, is likely to be abandoned in the wake of the new study linked above.

What's new in ACLS? The most important changes in the 2010 ACLS guidelines impacted the hospital as an institution more than the individual provider. These included the post-resuscitation bundle and the organization of stroke care. So it's your hospital administrators as much as the doctors who need training in ACLS now! Concerning the individual provider the guidelines did make some changes which reflect an increased emphasis on effective compressions. Unfortunately these changes did not go far enough and remain years behind best evidence. In the post linked above I contrasted ACLS 2010 recommendations with current best evidence.

STEMI versus NSTEMI---a dubious distinction. Does the distinction between STEMI and NSTEMI go beyond the obvious fact that some MI patients have ST elevation and others do not? Ever since door to balloon time for STEMI became a performance measure certain unintended consequences of inappropriate treatment have come to light. Aside from the obvious ones---patients with benign early repolarization or pericarditis getting rushed to the cath lab (yes, it happens)---there are the increasingly reported examples of patients with acute coronary occlusions who are denied timely reperfusion because they lack diagnostic ST segment elevation. Many patients with acute coronary occlusions have “NSTEMI.” Although their need for reperfusion is just as urgent as those with STEMI the performance metric for MI does not recognize them and they may wind up under treated.

That's why the large review of subtypes of MI published in 2010, cited in the post linked above, was so timely. It showed that while patients with NSTEMI tended to be older and have infarctions which were subsequent there was no difference between STEMI and NSTEMI in terms of pathology or outcome.

This is not to say that ST segment elevation is unimportant. It is the most obvious electrocardiographic sign of acute MI and, more than ST depression, helps localize the infarction.

Fluid resuscitation in acute pancreatitis---less may be more. Fluid resuscitation in acute pancreatitis should be guided by perfusion and volume assessment. While many patients will require large volume fluid therapy on the front end, according to a study published last year that strategy may not be appropriate for all patients as is conventionally taught.

New oral anticoagulants. Well, maybe this one is a game changer. Although these agents don't require monitoring of coagulation tests they do require vigilance of a different type, and there's a lot of new stuff hospitalists need to know.

1 comment:

Min-Han said...

Great summary!