Thomas Frederickson MD FACP SFHM MBA Medical Director Hospital Medicine Alegent Creighton Health Topics Transfusion Medicine Anticoagulation Therapeutics Perioperative Medicine Critical Care ID: 718182
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Slide1
Update in Hospital Medicine 2013
Thomas Frederickson, MD, FACP, SFHM, MBA
Medical Director, Hospital Medicine
Alegent Creighton HealthSlide2
Topics
Transfusion Medicine
Anticoagulation
TherapeuticsPerioperative MedicineCritical CareChoosing Wisely
Update in Hospital Medicine 2013Slide3
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, OAPSH: Cholecystectomy, TKA on RMeds: Diltiazem, Lisinopril, Metformin, Warfarin, Acetaminophen, PRN Ibuprofen about twice per week
Update in Hospital Medicine 2013Slide4
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 CPPE: Gen – NAD, 128/74, 14, 108, 36.6, wt 56 kgENT – scleral pallor
CV –
Irregular, no Murmur
Update in Hospital Medicine 2013Slide5
Case 1cont.
Pulm
–
CTA, non laboredAbd –
NABS, no masses, mild mid-
epigastric
tenderness without G/R tendernessExt – no C/C/ENuero – non-focal, A&OX3Labs – INR 3.6, PTT 31.1, Hb
6.7, HCT 20.1, BS 187, rest of CBC and CMP WNL
Update in Hospital Medicine 2013Slide6
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 2013Slide7
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 >9Cont 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 2013Slide8
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
NEJM,
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 strategyExclusions – LGIB, exsanguination, shock, active coronary syndromeEndpoint – 6 week mortalityResults – 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 2013Slide9
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 2013Slide10
Question 2
When should Warfarin be restarted?
In one month
In 2 weeksIn 4 days
Never – are you crazy!!
Update in Hospital Medicine 2013Slide11
Risk of thromboembolism
, recurrent hemorrhage, and death after
warfarin
therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172:1484-9Retrospective 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 eventsNot restart group – 11 thromboembolic events, including 3 deaths from CVATake home – restart Warfarin after GIB
Update in Hospital Medicine 2013Slide12
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 2013Slide13
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 0Enoxaparin 40 mg sub-q starting POD 0 and restart Warfarin POD 0SCDs starting POD 0 and Warfarin starting POD 0Update in Hospital Medicine 2013Slide14
Predictors of major bleeding in peri-procedural anticoagulation management
.
J
Thromb Haemost. 2012;10:261-7.
Cohort study
2,182 patients on long term Warfarin
Study peri-procedural bleeding associated with LMWH bridging1496 received bridging, 686 did not5.1% bleeding, 2.1%major bleedingBridge - 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 2013Slide15
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: appendectomyMeds: fluticasone/
salmeterol
,
tiotropium, albuterol, amlodipine, metformin, glimepiride
Update in Hospital Medicine 2013Slide16
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 2013Slide17
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 2013Slide18
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 204CXR: Hyperinflation, no acute infiltrateUpdate in Hospital Medicine 2013Slide19
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 2013Slide20
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 dailyConsult neuro, they will know what to do
Update in Hospital Medicine 2013Slide21
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 vs Clopidogril 1.01 (.93-1.08)ICH – Dual vs ASA.99 (.70-1.42)Dual vs
Clopidogrel
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 2013Slide22
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 2013Slide23
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 2013Slide24
REDUCE
JAMA
. 2013;390(21):2223-2231
Short-term vs. conventional glucocorticoid therapy in
AE-COPD
Randomized, placebo-controlled
, double-blinded, non-inferiority314 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 2013Slide25
Question 6
What are potential complications of this patient’s therapy with levofloxacin
Peripheral neuropathy
Tendon damage
Hyperglycemia
Hypoglycemia
Update in Hospital Medicine 2013Slide26
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 cephalosporinsSevere hyperglycemia vs macrolides (per 1,000 patients)Moxifloxacin
(6.9
vs
1.6)Levofloxacin
(3.9)
Ciprofloxacin (4.0)
Severe hypoglycemia
vs
macrolides
(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 2013Slide27
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.pdfFDA required a label changes to warn of risk for possibly permanent nerve
damage
Previously was part of package insert only
IV and oralCan be permanent and disablingOnset can be in as little as three days FDA reporting system cannot calculate riskKnown since 2004Update in Hospital Medicine 2013Slide28
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 2013Slide29
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 2013Slide30
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-laboredAbd:
NABS, soft, NT, no masses
MS:
externally rotated L foot, shortened L leg
Ext:
no C/C/E
Update in Hospital Medicine 2013Slide31
Case 3 cont.
Neuro:
A&OX3
Labs:
CPC, CMP,
coags
all normal except BS 159, Troponin < 0.04EKG: Inferior Q waves seen on previous EKG, SRL Hip x-ray: L non-displaced femoral neck fractureHospital 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 2013Slide32
Question 7
What is your plan for post operative cardiac surveillance?
N
one
Telemetry monitoring
Telemetry monitoring and serial troponins
Consult cardiology, they will know what to doUpdate in Hospital Medicine 2013Slide33
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 85169 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 2013Slide34
Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency
department.
J Hosp Med. 2013;8:13-9Describe risk factors
for unplanned
ICU transfer within 24 hours of ward arrival
from the ED178,315 ED to floor admissionsAt 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 sexDecreased 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 2013Slide35
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 2013Slide36
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 2013Slide37
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 2013Slide38
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 2013Slide39
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 2013Slide40
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 prophylaxisConsider a shorter 5 day course of prednisone for AE-COPDUpdate in Hospital Medicine 2013Slide41
Summary
Know the precautions associated with quinolones including
dysglycemia
in diabetic patients and peripheral neuropathyConsider 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 2013Slide42
Important recent practice guidelines 2012-13
Guyatt
GH,
Akl EA, Crowther M,
Gutterman
DD,
Schuunemann HJ;American College of Chest Physicians Antithrombotic Therapy and Preventionof Thrombosis 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-47SCarson 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
Umpierrez
GE, Hellman R,
Korytkowski
MT,
Kosiborod
M, Maynard
GA,
Montori
VM, et al; Endocrine Society.
Management of hyperglycemia in
hospitalized patients
in non-critical care setting: an endocrine society clinical
practice guideline
. J
Clin
Endocrinol
Metab
.
2012;97:16-38
Jneid
H, 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 2013Slide43
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
Tafur
AJ,
McBane
R 2nd,
Wysokinski
WE, et al.
Predictors of
major bleeding
in
peri
-procedural anticoagulation management. J
Thromb
Haemost
.
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 a
l 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 2013Slide44
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
Leuppi
JF, 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):2223-2231Gupta 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 2013Slide45
Disclosures and Conflicts of Interest
I WISH!
None
QUESTIONS?
Update in Hospital Medicine 2013