Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your perspective on the role of respiratory therapists in managing a patient who is dyssynchronous on their current mode of mechanical ventilation?
Yes, it’s in the scope of their practice to adjust vent settings for various reasons. At my practice, I work with them closely so I am aware of the changes being made. And this goes both ways. If I end up making changes, I make it a point to let the RTs know what changes I made.
When would you consider percutaneous mechanical aspiration of vegetation in right-sided endocarditis?
Percutaneous options for right-sided endocarditis is a growing field. We have utilized it at our institution with the AngioVac in complex ACHD (Eilers et al., PMID 36448943); others have utilized Inari (Whitbeck and Chambers, PMID 35880845 and Bisleri et al., PMID 33155779). Some have even ventured ...
Do you typically recommend inpatient stroke evaluation for patients with incidentally found asymptomatic stroke on outpatient imaging?
This of course depends on so many variables, some scenarios and questions that matter in making the decision: Why was the imaging done in the first place? Not relevant to stroke or imaging was done because of TIA? What were the initial symptoms? Are you suspecting a large vessel occlusion (shocking...
How do you approach treatment of septated parapneumonic pleural effusions that do not satisfy traditional criteria for complicated effusion after diagnostic thoracentesis?
Septated effusion is a complicated effusion, whether it is empyema, parapneumonic, or malignant, and usually, they are exudative. By definition, untreated parapneumonic effusion will become empyema. Septations <4-6 week duration are usually fibrinous and can be lysed with tPa/DNase instilled through...
Would you use PCC for clotting factor repletion in acute life threatening hemorrhage in a patient with elevated INR from coagulopathy of liver disease?
I do not use KCentra in this clinical situation. Firstly, the INR is validated for vitamin K antagonists (VKA) therapy only. The VKAs inhibit the synthesis of factors II, VII, IX, and X while the liver produces more clotting factors such as fibrinogen, II, V, VII, IX, X, XI, XII, etc. The INR has no...
In a patient hospitalized for several days with a refractory pain crisis would you ever consider transfusion, either simple or possibly exchange in an attempt to get the patient over the crisis?
While chronic transfusion therapy has been shown to prevent acute vaso-occlusive pain episodes (see studies that used chronic transfusion to prevent primary and secondary stroke), there are limited data to determine if they are effective for treatment of acute pain caused by vaso-occlusion. There ha...
What is a reasonable approach to monitoring mechanical valve function if systemic anticoagulation needs to be held in the setting of an acute intracranial hemorrhage?
Most modern mechanical aortic valves can tolerate being off anticoagulants for up to 2 weeks. The mitral valves however are more of a concern and I generally recommend an echocardiogram at 1 week and then reassess the risk of rebleed versus valve thrombosis.
Do you routinely continue using TPA/Dornase for treatment of empyema, if there is accumulation of new sero-sanguinous output from the chest tube after the initial treatment?
In my practice, if there is an accumulation of serosanguinous output after initial treatment, further treatment with tPa/ dornase depends on several factors. Hct of drainage - if > 50%, will not give further dose. If a patient is coagulopathic or receiving anticoagulation for a medical condition af...
Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?
In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful o...
Do you proceed with outpatient hemodialysis for an asymptomatic ESKD patient who has missed the last three hemodialysis sessions?
In the ideal world, missing too many HD sessions (no magical number) can predispose patients to quick normalization of low Na or very high BUN which we don’t want to! Also, asymptomatic patients don’t mean okay volume, patients' BP might be as high as 200s and this needs extra sessions to get back t...