Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
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.