Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the management of GVHD prophylaxis in the setting of severe infection?
GVHD prophylaxis the 1st ~ 3 months after alloSCT is paramount and immunosuppression withdrawal might cause GVHD which can in turn exacerbate or cause infection given the need of corticosteroids to control it. Having said that, case-by-case management is important. As an example, alloSCT using a PTC...
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
How would you approach the treatment of a patient who, during a hospitalization, was initially diagnosed with TTP and treated with PLEX with good response, but renal biopsy then resulted class IV LN along with changes of thrombotic microangiopathy?
This is a challenging scenario; the literature consists of case reports and case series. In clinical practice, combining PLEX with cyclophosphamide or Rituximab is a possibility.I was recently involved in a case of an SLE patient with refractory TTP (no nephritis) where Caplacizumab (Scully et al.,P...
Do you routinely use vasopressin in the management of RV failure leading to shock state in the absence of an obvious treatable cause such as infarction or PE?
It seems that there is a vasopressin dose-dependent effect on PA pressures. The doses we usually use for septic shock (0.03 or less) have some degree of pulmonary vasodilation (for example, Tsuneyoshi et al., PMID 11373409). Higher doses may have the opposite effect (Leather et al., PMID 12441768). ...
What is your preferred PO afterload-reducing agent immediately after being weaned off inotropic support in cardiogenic shock?
Once inotropic agents have been successfully weaned and hemodynamics support the initiation of oral guideline-directed medical therapy, then I often start with oral afterload-reducing agents, but there is limited data regarding which agent is superior or provides the maximal benefit. Anecdotally, if...
How do you manage postoperative head and neck cancer patients who have difficulty completing simulation due to copious secretions?
In addition to elevating the head/shoulders as much as technically feasible, if there aren't contraindications, I've used a scopolamine patch applied two days before the sim with variable success.
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...
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...