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Update in Hospital Medicine 2013

Update in Hospital Medicine 2013. Thomas Frederickson, MD, FACP, SFHM, MBA Medical Director, Hospital Medicine Alegent Creighton Health. Topics. Transfusion Medicine Anticoagulation Therapeutics Perioperative Medicine Critical Care Choosing Wisely. Case 1. CC: dizzy and black stools

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Update in Hospital Medicine 2013

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  1. Update in Hospital Medicine 2013 Thomas Frederickson, MD, FACP, SFHM, MBA Medical Director, Hospital Medicine Alegent Creighton Health

  2. Topics • Transfusion Medicine • Anticoagulation • Therapeutics • Perioperative Medicine • Critical Care • Choosing Wisely Update in Hospital Medicine 2013

  3. Case 1 CC: dizzy and black stools HPI: M.S. is an 78 yo female with 2 day history of 6 black, foul smelling sticky stools, and one day history of mild dizziness, fatigue, DOE and nausea. No vomiting or syncope. PHM: HTN, DMII, a-fib, OA PSH: Cholecystectomy, TKA on R Meds: Diltiazem, Lisinopril, Metformin, Warfarin, Acetaminophen, PRN Ibuprofen about twice per week Update in Hospital Medicine 2013

  4. Case 1cont. SH: lives alone, independent in ADLs, widowed, non smoker and non drinker FH: CAD in father who died at 64, son with CAD post CABG ROS: otherwise neg, no abd pain, no CP PE: Gen – NAD, 128/74, 14, 108, 36.6, wt 56 kg ENT – scleral pallor CV – Irregular, no Murmur Update in Hospital Medicine 2013

  5. Case 1cont. Pulm – CTA, non labored Abd – NABS, no masses, mild mid-epigastric tenderness without G/R tenderness Ext – no C/C/E Nuero – non-focal, A&OX3 Labs – INR 3.6, PTT 31.1, Hb 6.7, HCT 20.1, BS 187, rest of CBC and CMP WNL Update in Hospital Medicine 2013

  6. Case 1cont. ED Course – 3 units FFP, 2 units RBC, I L NS, transfer to ICU, 2 16 gauge IV were placed, GI consult, Pantoprazole bolus and drip ordered, EGD scheduled for the following morning, H/H every 6 hours Update 10 hours later – One more episode of melena, no N/V, repeat Hb 7.7, VSS, HR 89 Update in Hospital Medicine 2013

  7. Question 1 What is you RBC transfusion strategy for this patient? • Transfuse 2 units RBC now, cont Q6 hr H/H, transfuse to a Hb target >9 • Transfuse 1 units RBC now, cont Q6 hr H/H, transfuse to a Hb target >9 • Cont Q6 hr H/H, hold transfusion for now, transfuse to a Hb target >7 • GI is on board, let them worry about it! Update in Hospital Medicine 2013

  8. Transfusion Strategies for Acute Upper Gastrointestinal BleedingNEJM, 2013 Jan;368(1):11-21 • Objective – compare restrictive vs liberal transfusion strategy in UGIB • 921 patient with UGIB randomized to liberal (Hb target >10) or restrictive (Hb >7) transfusion strategy • Exclusions – LGIB, exsanguination, shock, active coronary syndrome • Endpoint – 6 week mortality • Results – survival in restrictive 95% vs 91 % for liberal (.55 HR, CI .33-.92, p=.02) • Also advantage for restrictive in re-bleeding 10% vs 16%, p.01) • Take home – better outcomes in UGI bleed with restrictive strategy, even in variceal bleeding Update in Hospital Medicine 2013

  9. Case 1cont. Further course – The patient remained stable, no further melena. She received no further blood products. EGD showed a GU with a clean base and no active bleeding, clot or visible vessel. On hospital day three the patient was discharged to home on her home medications except warfarin and ibuprofen. Pantoprazole 40 mg daily was added Update in Hospital Medicine 2013

  10. Question 2 When should Warfarin be restarted? • In one month • In 2 weeks • In 4 days • Never – are you crazy!! Update in Hospital Medicine 2013

  11. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172:1484-9 • Retrospective cohort study • GIB – 219 restart Warfarin in less than 2 weeks, 180 did not restart within 2 weeks • Restart Warfarin – • Mean time 4 days (IQR 2-9 days) • Thromboembolism HR .05 ( CI .01 - .58) • Death .31 (.15 - .62) • GIB 1.32 ( .5-3.57) • Restart group - 0 thromboembolic events • Not restart group – 11 thromboembolic events, including 3 deaths from CVA • Take home – restart Warfarin after GIB Update in Hospital Medicine 2013

  12. Case 1cont. One year later M.S., now 79 and has worsening L shoulder pain form OA. She was medically evaluated by her PCP prior to an elective L total shoulder arthroplasty. You are consulted in the hospital to manage her anticoagulation. Her exam and medications are unchanged. Her 5 mg per day dose of Warfarin was discontinued 5 days pre-op. Her post op Hb is 11.8, Cr. 0.5 and INR is 1.0 Update in Hospital Medicine 2013

  13. Question 3 How would you manage her anticoagulation? • Enoxaparin 1.5 mg/kg sub-q starting POD#1 and restart Warfarin POD 0 • Enoxaparin 1.5 mg/kg sub-q starting POD#2 and restart Warfarin POD 0 • Enoxaparin 40 mg sub-q starting POD 0 and restart Warfarin POD 0 • SCDs starting POD 0 and Warfarin starting POD 0 Update in Hospital Medicine 2013

  14. Predictors of major bleeding in peri-procedural anticoagulation management. J ThrombHaemost. 2012;10:261-7. • Cohort study • 2,182 patients on long term Warfarin • Study peri-procedural bleeding associated with LMWH bridging • 1496 received bridging, 686 did not • 5.1% bleeding, 2.1%major bleeding • Bridge - 3% major, no bridge -1% major (p=.017) • Major bleeding – Bridging <24 hr post op (HR 1.9, CI 1.6 – 3.4) • No major bleeding <24 hr if not on LMWH • Authors conclusions: bridge only high risk and at 48hr • Cautions – study groups had different characteristics Update in Hospital Medicine 2013

  15. Case 2 CC: can’t walk HPI: S.M is an 72 yo R handed male with a 7 hour history of difficulty walking. He had difficulty getting up from the kitchen table and had to hold on to furniture because of falling to the R. He had difficulty trying to dial his daughter’s PN. When his daughter arrived on her way home from work she noticed slurred speech and called 911 PHM: COPD, HTN, DM2, hospitalized one time in the past year for AE-COPD PSH: appendectomy Meds: fluticasone/salmeterol, tiotropium, albuterol, amlodipine, metformin, glimepiride Update in Hospital Medicine 2013

  16. Case 2 cont. SH: spokes ½ PPD, 50 pack year smoking history, 2 beers/day, lives with daughter, independent in ADLs, divorced FH: NC ROS: no F/C, cough with yellow sputum, no CP, DOE for past 2 days at 30 feet, neuro as above, otherwise neg PE: labored breathing and anxious Update in Hospital Medicine 2013

  17. Case 2 cont. VS: 149/92, 88, 24, 36.8, O2 sat 91% RA ENT: slightly dry oropharynx Card: Regular but distant S1S2 w/o murmur Pulm: mildly labored with expiratory wheezing with prolonged expiration Abd:NABS, soft, NT, no masses Ext: no C/C, trace pretibial edema Update in Hospital Medicine 2013

  18. Case 2 cont. Neuro:A&OX3, mildly slurred speech without word finding difficultly, no gross sensory deficits, diminished strength and coordination in the RUE and RLE, 2+ DTR patellar bilaterally, absent Achilles DTR bilaterally Labs: CPC, CMP, coags all normal except BS 204 CXR: Hyperinflation, no acute infiltrate Update in Hospital Medicine 2013

  19. Case 2 cont. EKG: NSR, RAFB Head CT: age appropriate atrophy only ED course: after passing a bedside swallow eval the patient was given ASA 325 mg po, methylprednisolone 60 mg IV, Levofloxacin 750 mg IV and admitted on your service to the stroke unit on a stroke protocol with a diagnosis of AE-COPD and ischemic CVA Update in Hospital Medicine 2013

  20. Question 4 What is appropriate anti-plate therapy for therapy patent? • ASA 325 pm PO daily • Clopridogrel 75 mg po daily • ASA 81 mg po daily plus Clopridogrel 75 mg po daily • Consult neuro, they will know what to do Update in Hospital Medicine 2013

  21. Risk–Benefit Profile of Long-Term Dual- Versus Single-Antiplatelet Therapy Among Patients With Ischemic Stroke A Systematic Review and Meta-analysis Ann Intern Med. 2013;159:463-470. • 7 trails, 39,574 patients, index CVA or TIA • Recurrent CVA – • Dual vs ASA OR .89 (CI .78-1.01) • Dual vsClopidogril 1.01 (.93-1.08) • ICH – • Dual vs ASA.99 (.70-1.42) • Dual vsClopidogrel 1.49 (1.17-1.82) • Conclusion – dual therapy is not better at preventing CVA, but is more likely to be associated with ICH than Clopidogrel mono-therapy Update in Hospital Medicine 2013

  22. Case 2 cont. Hospital course: The patient’s neuro deficits remained unchanged. He was continued on 325 mg ASA daily. He was initiated on levofloxacin 750 mg po daily to be continued for a total of 7 days and prednisone 40 mg daily. His wheezing and subjective dyspnea improved. His BS on his home medications plus SS sort acting insulin were below 180 and above 100. On day three he is being discharged to acute rehab. Update in Hospital Medicine 2013

  23. Question 5 What is the appropriate duration for the patients prednisone therapy? • 21 day taper • 14 days • 5 days • Let the rehab doc decide Update in Hospital Medicine 2013

  24. REDUCE JAMA. 2013;390(21):2223-2231 • Short-term vs. conventional glucocorticoid therapy in AE-COPD • Randomized, placebo-controlled, double-blinded, non-inferiority • 314 patients in ED (92% admitted) with severe COPD (mean FEV1-31%) and AE-COPD, randomized to 5 or 14 day course of 40mg/day of prednisone • No difference in repeat exacerbation at 6 month (5 days=36%, 14 days =37%) • No difference in median time to next exacerbation (5 days pred=45 days until next exacerbation, 14 days =29 days) • No difference in secondary endpoints: death, LOS, hyperglycemia, FEV1, dyspnea index • Conclusion: Short course prednisone non-inferior to long course in AE-COPD Update in Hospital Medicine 2013

  25. Question 6 What are potential complications of this patient’s therapy with levofloxacin • Peripheral neuropathy • Tendon damage • Hyperglycemia • Hypoglycemia Update in Hospital Medicine 2013

  26. Risk of severe dysglycemia among diabetic patients receiving levofloxacin, ciprofloxacin, or moxifloxacin in Taiwan Clin Infect Dis. 2013 Published on line Aug 15, 2013 • Population based study, 78,433 patients, floroquinolones, macrolides and cephalosporins • Severe hyperglycemia vsmacrolides (per 1,000 patients) • Moxifloxacin (6.9 vs 1.6) • Levofloxacin (3.9) • Ciprofloxacin (4.0) • Severe hypoglycemia vsmacrolides (per 1,000 patients) • Moxifloxacin (10 vs 3.7) • Levofloxacin (9.3) • Ciprofloxacin (7.8) • Diabetics using oral fluoroquinolones faced greater risk of severe dysglycemia. Update in Hospital Medicine 2013

  27. FDA requires label changes to warn of risk for possibly permanent nerve damage from antibacterial fluoroquinolone drugs taken by mouth or by injection. http://www.fda.gov/downloads/Drugs/DrugSafety/UCM365078.pdf • FDA required a label changes to warn of risk for possibly permanent nerve damage • Previously was part of package insert only • IV and oral • Can be permanent and disabling • Onset can be in as little as three days • FDA reporting system cannot calculate risk • Known since 2004 Update in Hospital Medicine 2013

  28. Case 3 CC: I’ve fallen and I can’t get up HPI: T.F. is an 86 yo female who fell while getting back into bed. She tripped over the upturned corner of a throw rug. She is experiencing pain in the L groin that radiates down the anterior aspect of her upper leg. She could not get up but was able to crawl to her phone and call for help. She has no other injuries or pain and no syncope. She had one previous fall 2 years ago. PHM: HTN, DMII, OA, macular degeneration, CAD post CABG in 1991, echo 18 mo ago with no WM abnormalities or significant valvular disease, grade 1 diastolic dysfunction PSH: CABG, TKA on R Meds: Metoprolol, Lisinopril, HCTZ, Metformin, ASA, Acetaminophen, Simvastatin Update in Hospital Medicine 2013

  29. Case 3 cont. SH: 20 pack year smoking history, quit in 1991, no EtOH, lives in assisted living, walks with a walker, widowed FH: NC ROS: no CP with exertion or at rest, no DOE, palpitations, orthopnea, PND, pedal edema, otherwise neg, BS usually <150, checks one time daily PE: resting comfortably in ED after 2mg IV morphine Update in Hospital Medicine 2013

  30. Case 3 cont. VS: 108/62, 66, 14, 36.4, O2 sat 97% RA Head and Neck: NC/AT, neck non tender CV: Regular S1S2 w/o murmur, bilateral palpable DP and AT pulses Pulm: CTA, non-labored Abd:NABS, soft, NT, no masses MS: externally rotated L foot, shortened L leg Ext: no C/C/E Update in Hospital Medicine 2013

  31. Case 3 cont. Neuro:A&OX3 Labs: CPC, CMP, coags all normal except BS 159, Troponin < 0.04 EKG: Inferior Q waves seen on previous EKG, SR L Hip x-ray: L non-displaced femoral neck fracture Hospital Course: The patient is admitted to you and you consult ortho. You let ortho and anesthesia know that she is a low to moderate risk for peri-operative cardiac complications and to proceed with surgery without further testing. Update in Hospital Medicine 2013

  32. Question 7 What is your plan for post operative cardiac surveillance? • None • Telemetry monitoring • Telemetry monitoring and serial troponins • Consult cardiology, they will know what to do Update in Hospital Medicine 2013

  33. Clinical presentation and outcome of perioperative myocardial infarction in the very elderly following hip fracture surgery. J Hosp Med. 2012;7:713-6. • Case control (2:1), retrospective study, 1,212 hip fx patient cohort, median age 85 • 169 with MI (14%), 92% in <48 hr post-op, 75% “silent” • Mortality MI vs no-MI- • In hospital 14.5% vs 1.2% • 30 day 17.4% vs 4.2% • 1 year 39.5% vs 23% • Limitations: 1998-02, limited use of b-blocker, statin and ACE-I • Conclusion – consider cardiac surveillance in elderly hip fx patients Update in Hospital Medicine 2013

  34. Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department.J Hosp Med. 2013;8:13-9 • Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED • 178,315 ED to floor admissions • At risk for ICU transfer <24 hr: • PN (OR 1.5, CI 1.2 – 1.9) • MI (1.5, 1.2 – 2.0) • Sepsis (2.5, 1.9 – 3.3) • COPD (1.4, 1.1-1.9) • Night admissions, male sex • Decreased odds - high volume ED, admissions to monitored transitional care • Conclusion – Respiratory conditions, MI and Sepsis should be triaged objectively out of the ED Update in Hospital Medicine 2013

  35. Choosing Wisely • Medical specialty societies were asked to “choose wisely” and identify five tests or procedures commonly used in their field, whose necessity should be questioned and discussed • Sponsorship - ABIM Foundation • Partnership with Consumer Reports to develop and disseminate patient-friendly materials Update in Hospital Medicine 2013

  36. Choosing Wisely • Aims - promote conversations between physicians and patients by helping patients choose care that is: • Supported by evidence • Not duplicative of other tests or procedures already received • Free from harm • Truly necessary Update in Hospital Medicine 2013

  37. Choosing Wisely - Adult Hospital Medicine • Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). Update in Hospital Medicine 2013

  38. Choosing Wisely - Adult Hospital Medicine • Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications. • Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke. Update in Hospital Medicine 2013

  39. Choosing Wisely - Adult Hospital Medicine • Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation. • Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability. Update in Hospital Medicine 2013

  40. Summary • In UGIB use a transfusion threshold in most patients of 7 mg/dl • Consider resuming appropriate anticoagulation at 4 days for your patients with GI bleeds • Use heparin bridging only in high risk patients and only at 48 hours post-op • Avoid dual antiplatelet therapy for stroke prophylaxis • Consider a shorter 5 day course of prednisone for AE-COPD Update in Hospital Medicine 2013

  41. Summary • Know the precautions associated with quinolones including dysglycemiain diabetic patients and peripheral neuropathy • Consider monitoring for post-op cardiac ischemia in elderly hip fracture patients • Consider establishing objective criteria in your hospital for ICU admissions for cardiac and respiratory conditions, and for sepsis • Use Choosing Wisely for quality improvement projects in your hospital Update in Hospital Medicine 2013

  42. Important recent practice guidelines 2012-13 • Guyatt GH, Akl EA, Crowther M, Gutterman DD, SchuunemannHJ;AmericanCollege of Chest Physicians Antithrombotic Therapy and PreventionofThrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:7S-47S • Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, et al; Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49-58 • UmpierrezGE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, MontoriVM, et al; Endocrine Society. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J ClinEndocrinolMetab. 2012;97:16-38 • JneidH, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE Jr, et al; 2012 Writing Committee Members. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-St elevation myocardial infarction : a report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines. Circulation. 2012;126:875-910 • Dellinger, RP, et at. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637 Update in Hospital Medicine 2013

  43. Studies Sites • Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, SantalóM, Muñiz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan;368(1):11-21. • Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172:1484-91 • TafurAJ, McBane R 2nd, Wysokinski WE, et al. Predictors of major bleeding in peri-procedural anticoagulation management. J ThrombHaemost. 2012;10:261-7. • Meng Lee, MD; Jeffrey L. Saver, MD; Keun-Sik Hong, MD, PhD; Neal M. Rao, MD; Yi-Ling Wu, MS; and Bruce Ovbiagele, MD, MS Risk–Benefit Profile of Long-Term Dual- Versus Single-Antiplatelet Therapy Among Patients With Ischemic Stroke A Systematic Review and Meta-analysis Ann Intern Med. 2013;159:463-470. • Chou HW, Wang JL, Chang CH, et al Risk of severe dysglycemia among diabetic patients receiving levofloxacin, ciprofloxacin, or moxifloxacin in Taiwan Clin Infect Dis. 2013 Published on line Aug 15, 2013 Update in Hospital Medicine 2013

  44. Studies Sites • US Food and Drug Administration. FDA Drug Safety Communication: FDA requires label changes to warn of risk for possibly permanent nerve damage from antibacterial fluoroquinolone drugs taken by mouth or by injection. http://www.fda.gov/downloads/Drugs/DrugSafety/UCM365078.pdf • LeuppiJF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231 • Gupta BP, Huddleston JM, Kirkland LL, et al. Clinical presentation and outcome of perioperative myocardial infarction in the very elderly following hip fracture surgery. J Hosp Med. 2012;7:713-6. • Delgado MK, Liu V, Pines JM, et al. Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system. J Hosp Med. 2013;8:13-9 • Choosing Wisely, Society of Hospital Medicine – Adult Hospital Medicine, Five Things Physicians and Patients Should Question http://www.choosingwisely.org/doctor-patient-lists/society-of-hospital-medicine-adult-hospital-medicine/ Update in Hospital Medicine 2013

  45. Disclosures and Conflicts of Interest • I WISH! • None QUESTIONS? Update in Hospital Medicine 2013

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