Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What would be a reasonable means of mechanical circulatory support as a bridge to AVR for patients with severe aortic regurgitation complicated by cardiogenic shock?
Options are limited when dealing with severe aortic regurgitation. LAVA-ECMO should be considered to provide needed support. This can reduce the increased left-sided filling pressures and urgent surgery is warranted. Tandem heart can also be considered to help provide needed support without increase...
Should all pregnant patients with newly reduced LVEF <45% be referred as soon as possible to advanced heart failure given high risk for maternal morbidity/mortality in setting of suspected peripartum cardiomyopathy?
The ESC EURObservational Research Programme demonstrated that at six months, in women with peripartum cardiomyopathy: Left ventricular function recovery occurred in 46% of women, whereas 23% continued to have persisting and severe left ventricular dysfunction Re-hospitalization rate was one in 10, a...
What is your approach to weaning IABPs?
The weaning of IABP has varied tremendously across facilities and even providers. To my knowledge, there is no evidence-based method for weaning an IABP. However, there was a beautiful expert-consensus paper released recently that provides excellent scaffolding. Use Table 4 from the article below as...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...
Which hemodynamic parameters can be used to titrate positive pressure ventilation in preload dependent settings such as RV failure, cardiac tamponade, HOCM or hemodynamically significant PE?
As this question alludes, the application of positive pressure ventilation influences cardiac hemodynamics. Key principles of these cardiopulmonary interactions are outlined nicely by Alviar and colleagues (1) in a well-done review. In contemplating this question, it is important to consider the sep...
How would you approach a patient incidentally found to have PET avid large vessel vasculitis on CT angiogram during pre CABG workup?
Observational data from cohorts of patients with Takayasu arteritis has shown that patients with active vasculitis undergoing surgical intervention are more likely to require re-operation (e.g. Fields et al., PMID 16414389).Based on such data, the ACR/VF guidelines for the management of large vessel...
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...
How would you manage anti-platelet therapy in patients presenting with ischemic stroke and have a history of von Willebrand disease?
I follow the ASH ISTH NHF WFH 2021 guidelines, recommendation 3: "In patients with VWD and cardiovascular disease who require treatment with antiplatelet agents or anticoagulant therapy, the panel suggests giving the necessary antiplatelet or anticoagulant therapy over no treatment (conditional reco...
Do you routinely start full dose anticoagulation in new onset atrial fibrillation in the ICU?
Yes. (Based on CHADS2 + Absence of absolute contraindications, i.e., active uncontrolled bleeding or coagulopathy.)
What is your threshold to start stress dose steroids in the management of patients with septic shock?
Absent long-term use at baseline, I do not routinely start stress dose steroids for patients with septic shock. I reserve steroids for patients with a persistent vasopressor requirement despite adequate volume resuscitation and treatment of the underlying source of infection.