The patient with cirrhosis: poised to bleed or poised to clot?

It turns out to be a little of both. A number of reviews have addressed this. [1] [2] [3]  Here are some of the key points:

The old maxim that cirrhotic patients are auto-anticoagulated is a myth. Severe liver disease is associated with a delicate balance between bleeding and clotting. In general, cirrhosis tends to be a hypercoagulable state. The relative risk for VTE in such patients has been estimated at around 2.

 

What are the mechanisms for the hypercoagulability of liver disease?

In primary hemostasis, while platelet numbers are often decreased these platelets tend to be hyper-functional. This is due to low levels of ADAM TS 13, correspondingly increased levels of VW factor and multifactorial endothelial dysfunction.

In secondary hemostasis, reasons for hypercoagulability include decreased levels of liver dependent natural anticoagulants such as protein C, protein S, and antithrombin. Factor VIII (not synthesized in the liver) tends to be increased.

There is also impaired fibrinolysis with increased levels of PAI-1 and decreased levels of plasminogen.

What are the clinical implications?

Traditional hemostatic tests are generally used but are of limited reliability. There's been increasing interest in global hemostatic tests such as viscoelastic assays which are conceptually more valid but are not yet ready for translation into clinical practice.

For low risk procedures, prophylactic hemostatic products peri-procedure are generally not indicated.

Antithrombotic treatments should be given in accordance with standard clinical indications recognizing a potentially increased risk of bleeding.

DOACs can be used in many patients but certain published restrictions apply.

Special circumstances where warfarin is favored over DOACs

 When is warfarin favored over DOACs?

 Valvular atrial fibrillation. 

This term is becoming obsolete. For anticoagulation for stroke prevention in atrial fibrillation  DOACs are contraindicated and warfarin favored in severe rheumatic mitral stenosis and mechanical prosthetic valves.

Liver disease. 

If Child Pugh is C DOACs are not recommended. If B, apixaban and rivaroxaban can be used “with caution” (FDA labeling ).   Child Pugh calculator.

 Antiphospholipid syndrome. 

Warfarin is favored (Up to Date). 

Morbid obesity: 

DOAC is okay for BMI up to 40. Above 40 rivaroxaban and apixaban are acceptable but other DOACs should be avoided. 

History of gastrectomy or weight loss surgery: 

Warfarin preferred. This review summarizes the rationale and recommendations regarding morbid obesity and patients who have had weight loss surgery.

In addition, certain drug interactions with DOACs are category X thus prohibiting use.

Myths and facts in antibiotic stewardship

The current issue of the American Journal of Medicine (the Green Journal) has an article titled Top Myths of Diagnosis andManagement of Infectious Diseases in Hospital Medicine. This is one of the better articles pertaining to antibiotic stewardship that I have seen. Ten myths are listed. They are not complete myths (exceptions apply to just about all of these principles); rather, they are misconceptions.

Myth one: antibiotics do no harm. High-level data refute this myth. For example, a recent metaanalysis showed that the use of procalcitonin guidance to shorten the duration of antibiotic therapy was associated with lower mortality.

Myth two: antibiotic durations of 7, 14, or 21 days are typically necessary. Although these are common recommendations, evidence is lacking. In many situations (and there are exceptions) shorter duration therapy is as good as longer duration. Examples include 3 to 5 days for community acquired pneumonia; eight days for nosocomial pneumonia; 5 to 7 days for pyelonephritis; four days for intraabdominal infection; five days for acute exacerbations of COPD and 5 to 6 days for cellulitis. There are notable exceptions. Certain deep-seated and difficult to eradicate infections are not candidates for either shorter duration or procalcitonin guidance for discontinuation. These include tuberculosis, meningitis, prosthetic joint infections, staphylococcal bacteremia, endocarditis and invasive fungal infections. The same caution applies to some immunocompromised patients.

Myth three: if one drug is good two (or more!) must be better. This requires nuance.There are some indications for combination therapy. They are exceptions rather than the rule. The main indication for combination therapy is initial empiric treatment for life-threatening infection such as sepsis. The rationale is to cover all likely pathogens. De-escalation is appropriate if and when culture and sensitivity results indicate that a single agent would be appropriate. This principle is also applied in meningitis where in patients 50 years of age or older we include listeria coverage such that in non pen allergic patients ampicillin is added to the combination of ceftriaxone and vancomycin. Also in meningitis the combination of ceftriaxone and vancomycin accommodates the possibility of relative resistance of strep pneumo which might cause treatment failure with cephalosporin monotherapy. In community acquired pneumonia requiring hospitalizations the guidelines call for combination cephalosporin and macrolid therapy. For patients admitted to ICU it is recommended that MRSA coverage be added (this is in the IDSA MRSA guideline, not the pneumonia guidelines).

A frequently asked question is what to do about serious gram negative infections. Traditionally “double coverage“ with two gram-negative agents has been used. For the most part this is not supported by evidence. One exception is in the initial (empiric) antipseudomonal coverage for HAP/VAP., the guidelines for which indicate double coverage initially which should be de-escalated later if microbiologic data allow. In contrast, the CAP guidelines for patients with pseudomonas risk recommend monotherapy---not double coverage--from the start.

Myth four: oral antibiotics are not as good as IV antibiotics for hospitalized patients. This is, in general, a myth but there are exceptions. IV therapy is not inherently better than oral if there’s adequate bioavailability with the oral agent and if susceptibilities allow switch to an oral agent. Cautions apply in bacteremia. Some of these (eg staphylococcal bacteremia ) require intravenous therapy for the entire course. In other bacteremic infections step down to oral agents may be appropriate. Examples include certain streptococcal bacteremias and gram-negative bacteremic urinary tract infections. In such cases a switch to oral therapy can be considered as early as day four.

Myth five: bacteria in the urine signifies a UTI and should be treated. If it is asymptomatic treatment is only warranted in pregnancy and patients about to undergo a urologic procedure.

Myth six: history of penicillin allergy means the patient can never receive a beta lactam antibiotic. Former thinking was that there’s a 10 to 15% cross sensitivity rate between penicillin and cephalosporins. More recent findings indicate that the cross sensitivity rate to penicillin allergy is more like 3% for cephalosporins and 1% for carbapenems. The article provides some general principles for decision making in patients with purported penicillin allergy. For reactions that are mild and non specific a cephalosporin can be given. If the reaction was anaphylactoid either an alternative antibiotic to a cephalosporin or penicillin desensitization is recommended. Severe non anaphylactic reactions such as Stevens-Johnson syndrome, toxic epidermal necrolysis and DRESS syndrome are in a different category. In those cases the use of any beta lactam is contraindicated as is penicillin desensitization.

Myth seven: antibiotics for surgical prophylaxis should be continued for 24 hours or more .

Myth eight: antibiotics must be continued for as long as drains are in place. Although clinical judgment is required here there is no robust evidence to support such a practice.

Myth nine: nitrofurantoin can be used for UTIs only if the creatinine clearance is greater than 60. This is in accordance with product labeling but the data indicate 30 may be more reasonable cut off.

Myth ten: fluoroquinolones are first line agents for many infections. We now have mounting evidence of adverse effects (CNS toxicity,, tendon rupture, dysglycemias, irreversible neuropathy, QT prolongation and aortic dissection) such that fluoroquinolones have been relegated to a lower position in the sequence. They should be used only when safer and equally effective alternatives are not available.

In a related antibiotic stewardship topic this article from Cinical Infectious Disease looked at the utility of MRSA PCR screening. Negative PCR can allow for discontinuation or avoidance of MRSA therapy such as vancomycin in many situations. Those studied in the article were bloodstream infections, intra-abdominal infections, respiratory infections, wound infections and urinary tract infections. Negative predictive value was 93% or better in all those situations.

Diagnostic time out

What is a diagnostic time out? Succinctly defined, it’s a deliberate exercise in differential diagnosis and systematic clinical reasoning in the care of an individual patient. But wait, I hear someone say… isn’t that what we do already? Well, no. We’re all familiar with the traditional model for clinical reasoning that we’re taught in medical school but those of us in the real world of practice nowadays, if we’re honest, realize that it seldom happens. There’s just not enough time when you’re forced to see too many patients each day. And hospitalist incentives, with their emphasis on speed and quick adoption of specific diagnostic labels, run in opposition. What do we as hospitalists do instead? Well, aside from all the care pathways and metric incentives that tell us what to do, we rely on clinical instincts and rules of thumb. Because they bypass formal analysis, they save time. They serve as cognitive shortcuts. We call these heuristics. This method of thinking (fast, instinctive, intuitive) is sometimes known as system 1 thinking. It has the advantages of being efficient and fast and sometimes, in critical situations, life saving. But it comes at the cost of a certain error rate. In order to better understand the process of system 1 thinking we have given the various heuristics names and categories. I recently listed some of those in this post. 

If system 1 is our usual measure of processing to get around time constraints the alternative is system 2: formal clinical reasoning .  System 2 thinking was the topic of a recent paper in CriticalCare Clinics. Although based on a survey of people working in a NICU the article has general applicability. The authors contrast system 1 and system 2 thinking in this manner:

Dual process theory holds that individuals engaging in medical decision-making use one of 2 distinct cognitive processes: a system 1 process based on heuristics – the use of rapid pattern recognition and rules of thumb – or a system 2 process, based on deliberate analytical modeling and hypothesis generation. While invoking system one processes individuals can think fast and reflexively and can even operate at a subconscious level, using pattern recognition to sort vast amounts of clinical information quickly before an illness script that allows for the rapid elaboration of a differential diagnosis. In contrast system 2 processes require focused attention and are purposefully analytical, relying on deliberate counter-factual reasoning to generate hypotheses regarding the pathophysiologic mechanisms by which a patient’s symptoms are produced.

The authors introduced the concept of the diagnostic time out to describe this shift of thinking because it requires deliberate effort. It’s not going to arise spontaneously in the natural course of the ward routine. (The authors were not the first ones to use this term). The diagnostic time out can be considered the cognitive equivalent of the better known procedural time out.

Why is a diagnostic time out needed? Research on diagnostic error has indicated that while some instances are due to system problems (such as failure to communicate test results) most are cognitive errors. These can be linked to the heuristics of system 1 thinking. The diagnostic time out, or the deliberate exercise of system 2 thinking, is a way to complement these cognitive shortcuts with a more analytical process.

Some opinion leaders in the field of diagnostic error have suggested universal adoption of system 2 thinking. This is problematic due to time constraints. Besides, there are some essential benefits of system 1 thinking, particularly in acute life-threatening situations. The real trick is how best to selectively employ system 2 thinking. In other words what are the situations in which system 2 thinking should be used? The authors suggest handoff situations in complex patients including ER to hospitalist, off service/on service and ICU to ward transfers.

How does it work? The authors propose a template but it’s really just the traditional clinical reasoning process. One of their points really got my attention: during the time out diagnostic labels should be removed and replaced by signs, symptoms, manifestations and clinical concerns. This of course is the opposite of what your coders and hospitalist leaders want you to do.

What are some of the barriers to implementation? In addition to time constraints, fear of ambiguity is an important factor. We are afraid to admit what we don’t know. One thing you will never hear a hospitalist say out loud is “I’ll have to think about that.”

Stepford doctors

Ever since variation was declared to be an enemy of medicine there has been a multifaceted unrelenting effort to constrain the autonomy of clinicians.

In an article in the Medical Humanities journal titled “Stepford doctors”: an allegory GM Sayers described this trend creeping towards the ultimate creation of a workforce of Stepford doctors. 

From the paper:

The Stepford Wives, a novel by Ira Levin, provides the theme for this allegory. The men of Stepford belong to the Men’s Association. Their wives are “perfect”, in that they do nothing other than clean, cook, preen, and provide satisfaction without argument for their husbands. They are, furthermore, content with their lot, and believe that their previous interests and freedoms were self indulgent.

Applying the allegory to hospital medicine, Sayers wrote:

In the hospitals, doctors were pooled and moved like pawns to fill clinical slots, by masters who controlled both board and pieces...

The masters were not doctors; they were experts in managing time, costs, and doctors. They had not studied medicine, bioethics, or humanities; they were devoid of empathy. They did not treat patients, perform operations or do clinical research. They did not break bad news or get consent from patients for surgery. Nevertheless, they knew what sort of doctors they wanted—‘‘Stepford doctors’’. These were not ‘‘excellent’’ doctors, but ‘‘good enough’’ doctors, who would devote themselves to the masters’ objective of expediency, and the masters’ duty to balance the budget.

It is not completely clear how the masters changed the thinking and acting of so many doctors, but they did. Some of the doctors accepted the superficial plausibility of the reasoning that informed the masters’ demands. Some of the doctors themselves became masters, and they persuaded other doctors that the way the masters saw medicine was the way medicine should be.

 

The article was published in 2006 and might be considered dated but the premise is even more relevant today. In the words of the author: “This allegory cannot be concluded because it is on going.”

Are internal medicine’s core values effectively applied in today’s hospitalist practice?

Hospital medicine has changed. The change has been brought by business and regulatory pressures rather than the core values of internal medicine. Internal medicine’s core values are timeless.

Phillip Tumulty was famous as one of internal medicine’s great teachers. He was a lead faculty member in the department of internal medicine at Johns Hopkins for over 20 years. He published an article in JAMAInternal Medicine in 1977 in which he laid out some of the core values of internal medicine. Tumulty, an exemplar of internal medicine if their ever was one, had these things to say (paraphrasing from some of the points he made):

An internist is meticulous in the application of expertise in history and physical examination.

An internist develops a “referral practice” which leads to distinction among peers. (In other words, an internist is a specialist).

An internist “must not nod, nor grow bored, but sustain his enthusiasm through constantly searching for the unexpected in the seemingly obvious. Its occasional discovery in a patient’s problem hitherto passed over as routine brings self renewal.“ In other words the internist’s professional satisfaction feeds on being able to spot zebras in the morass of “bread and butter“ problems.

The internist should not be regarded “merely as some useful indispensable medical work horse, ably attending to the daily clinical chores.“

Tumulty summarizes his points this way: “some may say this is all very well but only as an idealistic concept of a kind of clinician and care that is no longer practical. I agree; it is indeed a concept of excellence. However, in the care of the sick, should one plan for less?“

Are the pressures and expectations placed on hospitalists today aligned with these core principles and values of internal medicine as articulated by Tumulty?

Update on management of the acute abdomen in critically ill patients

 

From a recent review in Current Opinion in Critical Care Medicine:

Purpose of review

The aim of this study was to describe important features of clinical examination for the surgical abdomen, relevant investigations, and acute management of common surgical problems in the critically ill.

Recent findings

Lactate remains a relatively nonspecific marker of gut ischemia. Dual energy computed tomography (DECT) scan can improve diagnosis of bowel ischemia. Further evidence supports intravenous contrast during CT scan in critically ill patients with acute kidney injury. Outcomes for acute mesenteric ischemia have failed to improve over time; however, increasing use of endovascular approaches, including catheter-directed thrombolysis, may decrease need for laparotomy in the appropriate patient. Nonocclusive mesenteric ischemia remains a challenging diagnostic and management dilemma. Acalculous cholecystitis is managed with a percutaneous cholecystostomy and is unlikely to require interval cholecystectomy. Surgeon comfort with intervention based on point-of-care ultrasound for biliary disease is variable. Mortality for toxic megacolon is decreasing.

Summary

Physical examination remains an integral part of the evaluation of the surgical abdomen. Interpreting laboratory investigations in context and appropriate imaging improves diagnostic ability; intravenous contrast should not be withheld for critically ill patients with acute kidney injury. Surgical intervention should not be delayed for the patient in extremis. The intensivist and surgeon should remain in close communication to optimize care.

The fight to curb antimicrobial resistance: how are we doing?

 

From a recent NEJM review on this topic:

In November 2019, the CDC released an updated version of its antibiotic-resistance report…

The new report reveals reductions in the incidence of infections caused by carbapenem-resistant acinetobacter species, multidrug-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and drug-resistant candida species. In addition, it identifies an increasing incidence of Enterobacterales that produce extended-spectrum beta-lactamase and drug-resistant Neisseria gonorrhoeae infections and the emergence of the multidrug-resistant yeast Candida auris.

Procalcitonin guided antibiotic treatment is beneficial in a variety of infections

From a recent report in the American Journal of Respiratory and Critical Care Medicine :

Rationale: Although early antimicrobial discontinuation guided by procalcitonin (PCT) has shown decreased antibiotic consumption in lower respiratory tract infections, the outcomes in long-term sepsis sequelae remain unclear.

Objectives: To investigate if PCT guidance may reduce the incidence of long-term infection-associated adverse events in sepsis.

Methods: In this multicenter trial, 266 patients with sepsis (by Sepsis-3 definitions) with lower respiratory tract infections, acute pyelonephritis, or primary bloodstream infection were randomized (1:1) to receive either PCT-guided discontinuation of antimicrobials or standard of care. The discontinuation criterion was greater than or equal to 80% reduction in PCT levels or any PCT less than or equal to 0.5 μg/L at Day 5 or later. The primary outcome was the rate of infection-associated adverse events at Day 180, a composite of the incidence of any new infection by Clostridioides difficile or multidrug-resistant organisms, or any death attributed to baseline C. difficile or multidrug-resistant organism infection. Secondary outcomes included 28-day mortality, length of antibiotic therapy, and cost of hospitalization.

Measurements and Main Results: The rate of infection-associated adverse events was 7.2% (95% confidence interval [CI], 3.8–13.1%; 9/125) versus 15.3% (95% CI, 10.1–22.4%; 20/131) (hazard ratio, 0.45; 95% CI, 0.20–0.98; P = 0.045); 28-day mortality 15.2% (95% CI, 10–22.5%; 19/125) versus 28.2% (95% CI, 21.2–36.5%; 37/131) (hazard ratio, 0.51; 95% CI, 0.29–0.89; P = 0.02); and median length of antibiotic therapy 5 (range, 5–7) versus 10 (range, 7–15) days (P less than  0.001) in the PCT and standard-of-care arms, respectively. The cost of hospitalization was also reduced in the PCT arm.

Conclusions: In sepsis, PCT guidance was effective in reducing infection-associated adverse events, 28-day mortality, and cost of hospitalization.

At a Glance Commentary

Scientific Knowledge on the Subject

The procalcitonin (PCT)-guided discontinuation of antibiotic therapy was demonstrated to reduce antibiotic exposure in patients with lower respiratory tract infections and/or sepsis in several randomized trials. However, the effect on the incidence of infections by resistant microorganisms has not been studied.

What This Study Adds to the Field

The PROGRESS (Procalcitonin-guided Antimicrobial Therapy to Reduce Long-Term Sequelae of Infections) trial was designed as a real-world pragmatic trial, enrolling patients with sepsis. The trial demonstrated that PCT-guided antimicrobial treatment in sepsis was effective in reducing infection-associated adverse events like infections by multidrug-resistant organisms and Clostridioides difficile, as well as in-hospital and 28-day mortality. Generated evidence implicates that PCT guidance in sepsis is a safe strategy with long-term benefits that may have a substantial impact on public health, particularly for countries with high baseline antimicrobial consumption.

Here is a related editorial in the same issue.

Since pneumonia patients were included in the study, do these results contradict the recommendations of the community acquired pneumonia guidelines? The idea that procalcitonin levels should not be measured in patients with community-acquired pneumonia is a popular misconception of the guidelines, often promulgated via institutional pathways. All the guideline says is that if clinical judgement leads to a diagnosis of pneumonia antimicrobial treatment should be initiated regardless of the initial procalcitonin result. The guideline does not preclude calcitonin guided therapy.

Widespread misunderstanding of hypoxemia, hypoxia and pulse oximetry

 

A recent article in the American Journal of Respiratory and Critical Care Medicine about hypoxemia and covid-19 concludes with this:

In conclusion, COVID-19 has engendered many surprises, but features that baffle physicians are less strange when contemplated through the lens of long-established principles of respiratory physiology.  

Read this paper when you're well rested and well fed and you will find it a great exercise in the physiology of hypoxemia. It's much more about that, and the misconceptions derived from our current obsession with pulse oximetry, than it is about covid.

First let's list what I think are some of the main ideas in the paper.

There was widespread over-reliance and misunderstanding of pulse oximetry.

There is not a simple correlation between dyspnea and hypoxemia.

The threat of hypoxemia is poorly understood by clinicians.

The seeming paradox of asymptomatic hypoxemia is not unique to covid-19 but is explained by well established principles of respiratory physiology.

Dyspnea is mediated by hypercapnia,  afferent signals produced by inflammatory stimuli, mechanical properties of the lungs and, least of all, hypoxemia.  As will be brought out in the physiology below, multiple  conditions seem to have a permissive effect on the dyspnea produced by hypoxemia.

Hypercapnia is a very important cause of dyspnea.   It has a permissive effect on hypoxemia as a cause of dyspnea. Hypercapnia causes a drop in pH in the blood perfusing the CNS respiratory control center.  An acute increase in pCO2 of 10 mm Hg quickly causes profound dyspnea. The situation is different for hypoxemia.  As pO2 falls there appears to be a threshold of 60 mm Hg  below which stimulation of ventilation and dyspnea occur. (The so called hypoxic drive). In terms of mechanism, hypoxemia stimulates the carotid bodies which send messages to the respiratory control center. From there impulses are relayed to the cortex cruising the sensation of dyspnea. The correlation between dyspnea and the ventilatory response to hypoxemia is poor. This response to hypoxemia is blunted if the pCO2 is 39 or below.  These responses are blunted in individuals with diabetes and individuals over 65 which constitute a high portion patients presenting clinically with covid.

Could covid have effects on the brain that blunt the dyspnea response? A similar question has been asked regarding the symptom of anosmia. ACE2, the receptor for covid-19, is expressed both in the carotid bodies and the nasal mucosa so mucosal effects rather than brain involvement could account for these manifestations. This is a question yet to be answered.

The authors imply that our usual concerns about low pulse oximeter  readings are misdirected.  Another quote from the article:

Physicians are fearful of hypoxemia, and many view saturations between 80% and 85% as life threatening. We served as volunteers in an experiment probing the effect of hypoxemia on breathing patterns; our pulse oximeter displayed an SpO2 of 80% for over an hour, and we were not able to sense differences between an SpO2 of 80% and an SpO2 of 90% (24). In investigations on control of breathing and oximeter accuracy, subjects experience an SpO2 of 75% (12), or briefly 45% (25), without serious harm. Tourists on drives to the top of Mount Evans near Denver experience oxygen saturations of 65% for prolonged periods; many are comfortable, whereas some sense dyspnea (25).

The finding of a low pulse oximetry reading does not enable a complete physiological assessment. Instead it should lead the clinician to ask: what's going on? Pitfalls in the interpretation of pulse oximetry were cited in the article. Correlation with blood gas readings deteriorates at lower levels of saturation. Accuracy of pulse oximetry is less in critically ill patients than in normal volunteers. The oxyhemoglobin dissociation curve should factor into any interpretation of pulse oximetry readings but this is seldom the topic of bedside discussions. Fever and low pH, common in critically ill patients, cause a shift of the curve to the right. This leads to lower saturation readings at a given pO2. It is an adaptive mechanism by which hemoglobin unloads oxygen more readily. Herein lies another reason why oxygen saturation correlates poorly with dyspnea: the carotid bodies respond to changes in pO2 but  not to oxygen saturation.

Further complicating the discussion is the definition of terms. Though not addressed in the article, there is the common confusion between hypoxemia and hypoxia. Low pO2 or saturation readings indicate hypoxemia. However, to diagnose hypoxia, which is a reduction in oxygen delivery to the tissues, one must apply the oxygen delivery equation. This equation takes into account hemoglobin bound oxygen, oxygen dissolved in plasma, hemoglobin concentration and cardiac output. As to  the definition of hypoxemia the authors point out that it has been an evolving concept. The definition of hypoxemia is not essential, but rather a matter of usage and convention. For example, in the 1990s it was often defined as the raw number without regard to the FiO2. Recently hypoxemia is more often referred to in terms of the oxygen requirement. Both are important: the former for estimating oxygen delivery and the latter for making an assessment of ventilation and gas exchange.

After reading this article I have the following concluding thoughts:

We over rely on pulse oximetry. Blood gases are underutilized.

Misunderstanding of pulse oximetry readings is widespread.

The hypoxemia of covid-19 is not as unique as popularly believed.

Elevated BP in hospitalized patients: what to do?

From a recently published review:

Elevated blood pressure is common in patients who are hospitalized. There are no guidelines and few recommendations to help inpatient providers manage patients with elevated blood pressure. There are no normal reported values for blood pressure in the inpatient and recording circumstances often widely vary. Many factors may influence blood pressure such as pain, anxiety, malaise, nicotine withdrawal, or withholding home medications. This review of available literature suggests potential harm and little to no potential benefit in treating asymptomatic patients with elevated blood pressure. This review also found no evidence that asymptomatic elevated blood pressure progresses to lead to end-organ damage. However, there are clear instances of hypertensive emergency where treatment is indicated. Conscientious adjustment of an anti-hypertensive regimen should be undertaken during episode of elevated blood pressure associated with end-organ damage.

What are the risks for bad outcomes in patients admitted with influenza?

From a recent study:

Highlights

A history of OSAS/CSAS, myocardial infarction and BMI greater than 30 are risk factors for ICU admission.

Non-survivors suffer more often from diabetes mellitus and (pre-existent) renal failure.

ICU patients develop renal failure and bacterial/fungal co-infections more often.

Abstract

Purpose

While most influenza patients have a self-limited respiratory illness, 5–10% of hospitalized patients develop severe disease requiring ICU admission. The aim of this study was to identify influenza-specific factors associated with ICU admission and mortality. Furthermore, influenza-specific pulmonary bacterial, fungal and viral co-infections were investigated.

Methods

199 influenza patients, admitted to two academic hospitals in the Netherlands between 01-10-2015 and 01-04-2016 were investigated of which 45/199 were admitted to the ICU.

Results

A history of Obstructive/Central Sleep Apnea Syndrome, myocardial infarction, dyspnea, influenza type A, BMI greater than 30, the development of renal failure and bacterial and fungal co-infections, were observed more frequently in patients who were admitted to the ICU, compared with patients at the normal ward. Co-infections were evident in 55.6% of ICU-admitted patients, compared with 20.1% of patients at the normal ward, mainly caused by Staphylococcus aureus, Streptococcus pneumoniae, and Aspergillus fumigatus. Non-survivors suffered from diabetes mellitus and (pre-existent) renal failure more often.

Conclusions

The current study indicates that a history of OSAS/CSAS, myocardial infarction and BMI greater than 30 might be related to ICU admission in influenza patients. Second, ICU patients develop more pulmonary co-infections. Last, (pre-existent) renal failure and diabetes mellitus are more often observed in non-survivors.

ICU or stepdown for your DKA patient?

From a recent study:

Highlights

In some centers, all Diabetic Ketoacidosis (DKA) patients are admitted to ICU.

No difference in in-hospital mortality was found between DKA patients admitted to step-down units or ICU.

DKA patients admitted to step-down units had significantly lower costs than those admitted to ICU.

Hospitals should preferentially consider monitoring of DKA patients in step-down units.

Abstract

Purpose

There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units.

Materials and methods

We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality.

Results

We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87–2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P less than 0.001).

Conclusions

Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

Delirium in hospitalized patients predicts readmission and other forms of increased post hospital utilization

Report here.

This is not surprising, since delirium in the hospital is often a sign of frailty.

Which patients post cardiac arrest need to go straight to the cath lab?

From a recent AHA scientific statement:

CAD is a common substrate, and its severity is a potential trigger for OHCA, especially in the case of shockable rhythms. Patients with VF/pVT OHCA should be considered at the highest severity of a continuum of acute coronary syndromes. Patients with VF/pVT have a significant burden of CAD: acute, chronic, or acute on chronic (Figure 8)…

Current guidelines recommend early CAG and reperfusion for postarrest patients manifesting ST-segment elevation after ROSC is achieved. However, because of a lack of conclusive randomized data and ongoing perceived clinical equipoise, there is no consensus guideline on the use of CAG and coronary revascularization in patients without ST-segment elevation on ECG. Multiple randomized trials addressing this question are underway. Until their completion, there is a significant body of observational studies that address the role of the CCL in this population.

The current evidence suggests that early access to the CCL in patients resuscitated from VF/pVT cardiac arrest is associated with 2- to 3-fold higher functionally favorable survival rates than more conservative approaches of late or no access to the CCL. This body of evidence, with potential for unmeasured selection bias, suggests that patients resuscitated from OHCA, especially those with presenting shockable rhythms, should be considered for early CAG, identification of reversible causes, and revascularization when indicated.

This is in line with the current ACLS guidelines, which say that if there’s ST elevation post ROSC an immediate trip to the cath lab carries a class I recommendation. For patients without STE, the guidelines give a IIa recommendation to go straight to the cath lab if the arrest is of suspected cardiac origin on clinical grounds.

Rates of cardiac testing prior to hip fracture surgery

From a recent report:

Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low- and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.

Management of acute kidney injury

From a review in the Journal of Hospital Medicine:

Acute kidney injury (AKI) is a common complication in hospitalized patients and is associated with mortality, prolonged hospital length of stay, and increased healthcare costs. This paper reviews several areas of controversy in the identification and management of AKI. Serum creatinine and urine output are used to identify and stage AKI by severity. Although standardized definitions of AKI are used in research settings, these definitions do not account for individual patient factors or clinical context which are necessary components in the assessment of AKI. After treatment of reversible causes of AKI, patients with AKI should receive adequate volume resuscitation with crystalloid solutions. Balanced crystalloid solutions generally prevent severe hyperchloremia and could potentially reduce the risk of AKI, but additional studies are needed to demonstrate a clinical benefit. Intravenous albumin may be beneficial in patients with chronic liver disease either to prevent or attenuate the severity of AKI; otherwise, the use of albumin or other colloids (eg, hydroxyethyl starch) is not recommended. Diuretics should be used to treat volume overload, but they do not facilitate AKI recovery or reduce mortality. Nutrition consultation may be helpful to ensure that patients receive adequate, but not excessive, dietary protein intake, as the latter can lead to azotemia and electrolyte disturbances disproportionate to the patient’s kidney failure. The optimal timing of dialysis initiation in AKI remains controversial, with conflicting results from two randomized controlled trials.

Should you get immunoglobulin levels on patients admitted with community acquired pneumonia?

From a recent study:

BACKGROUND: Immunodeficiency is an underrecognized risk factor for infections, such as community-acquired pneumonia (CAP).

OBJECTIVE: We evaluated patients admitted with CAP for humoral immunodeficiency.

DESIGN: Prospective cohort study.

SETTING: Inpatients

PATIENTS, INTERVENTION, AND MEASUREMENTS: We enrolled 100 consecutive patients admitted with a diagnosis of CAP from February 2017 to April 2017. Serum IgG, IgM, IgA, and IgE levels were obtained within the first 24 hours of admission. CURB-65 score and length of hospital stay were calculated. The Wilcoxon rank-sum test, Kruskal-Wallis test, and simple linear regression analysis were used in data analysis.

RESULTS: The prevalence of hypogammaglobinemia in patients with CAP was 38% (95% CI: 28.47% to 48.25%). Twenty-seven of 100 patients had IgG hypogammaglobinemia (median: 598 mg/dL, IQ range: 459-654), 23 of 100 had IgM hypogammaglobinemia (median: 38 mg/dL, IQ range: 25-43), and 6 of 100 had IgA hypogammaglobinemia (median: 36 mg/dL, IQ range: 18-50). The median hospital length of stay for patients with IgG hypogammaglobinemia was significantly higher when compared to patients with normal IgG levels (five days, IQ range [3-10] vs three days, IQ range [2-5], P = .0085). Fourteen patients underwent further immune evaluation, resulting in one diagnosis of multiple myeloma, three patients diagnosed with specific antibody deficiency, and one patient diagnosed with selective IgA deficiency.

CONCLUSION: There is a high prevalence of hypogammaglobinemia in patients hospitalized with CAP, with IgG and IgM being the most commonly affected classes. IgG hypogammaglobinemia was associated with an increased length of hospitalization. Screening immunoglobulin levels in CAP patients may also uncover underlying humoral immunodeficiency or immuno-proliferative disorders.