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Update in Hospital Medicine 2013 Update in Hospital Medicine 2013

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Update in Hospital Medicine 2013 - PPT Presentation

Thomas Frederickson MD FACP SFHM MBA Medical Director Hospital Medicine Alegent Creighton Health Topics Transfusion Medicine Anticoagulation Therapeutics Perioperative Medicine Critical Care ID: 718182

2013 hospital update medicine hospital 2013 medicine update patients case days risk therapy 2012 warfarin bleeding med day cont

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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