Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you prefer that hospitalized peritoneal dialysis patients use their own home dialysis equipment during the admission?
At our hospital, where we have our own PD equipment and RNs on call to set it up, we strongly prefer that patients DO NOT use their personal equipment. Liability concerns, but this approach won't work in a hospital where that backup does not exist. If the patient's choice is to have a TDC placed for...
What is your approach to the use of intravenous sodium thiosulfate for the management of calciphylaxis in a patient with end stage kidney disease and on hemodialysis?
We have sodium thiosulfate 25gm IV each dialysis given during the last hour of treatment as a standard order in our dialysis order set. We have seen a useful response in some patients after several weeks, but there are no clear trial-based data to support the use of this treatment. I would certainly...
What is your preferred strategy for controlling bleeding after transbronchial or endobronchial biopsies?
I use all Cold Saline, Wedging and EPI. If severe bleeding side down, therapeutic bronchoscope with suctioning blood till bleeding stops. Also to assess bleeding risk prior (low PLT, hx of ASA anticoagulation use) to bronchoscopy and during bronch watching oozing and stopping further biopsy can be v...
Do you start steroid therapy in a patient with pure ARDS without septic shock, or would you only consider steroids only in those with severe community acquired pneumonia?
I do not routinely start corticosteroids for pure ARDS, septic shock, or severe community-acquired pneumonia. In my mind, the DEXA-ARDS study was underpowered to answer the question. The recently published ESCAPE and CAPE-COD trials yielded conflicting results in CAP. In my mind, before adopting cor...
Would you recommend initiating RRT in a patient with tumor lysis syndrome and a phosphorus of 9 mg/dl or more who does not have symptomatic hypocalcemia or other indications for dialysis?
If the patient is urinating and maintaining a urine output with IV NS, and if there is no other indication for dialysis, then one can argue that the risks of RRT (catheter insertion and infection) outweigh any benefits.
How often and when do you consider trending NT-proBNP levels for patients with HFrEF admitted for acute decompensated heart failure?
NT-proBNP would normally be assessed upon admission for acute decompensated heart failure, and this is a Class 1 recommendation in the 2022 HF guidelines. I do not routinely re-check or trend NT-proBNP during the hospitalization until immediately prior to discharge. However, a predischarge NT-proBNP...
Have you encountered acute kidney injury after starting eltrombopag for aplastic anemia as part of triple immunosuppressive regimen with ATG and cyclosporine?
No, I have not. Of course, cyclosporine is intrinsically nephrotoxic and is the likely candidate. Sometimes, ATG will result in renal issues as well although less frequently.
When should headache treatment be escalated to inpatient IV lidocaine?
Overall, there is a lack of data (few studies) supporting the use of IV lidocaine. There are safety concerns, especially in the pediatric population. The other barrier is lack of expertise, most institutions need a sedation/anesthesia team for IV lidocaine administration even if it's done in outpati...
Do you transfuse platelets prior to central line placement in patients with platelet counts less than 50,000?
It depends. Bedside assessment is more reliable than objective data when it comes to platelets COUNT and platelet FUNCTION. We don't use a threshold number for triggering a platelet transfusion, rather base it on overall picture and bedside coagulopathy risk assessment.
Would you place an IVC filter in a patient with an acute intermediate risk PE and a proximal DVT who is on anticoagulation?
No. The only role for IVC filter use is in patients who can not tolerate anticoagulation (Marron et al., PMID 32795479).