Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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).
Do you recommend transfer to an institution with a PE response team for a patient with an intermediate risk PE?
This is an interesting and difficult question. It depends on the case of a high intermediate-risk submassive PE that we have. Whenever there is a debate on the approach, a relative contraindication for certain forms of anticoagulation, different approaches on a catheter-directed intervention, or a ...
What are the preferred inotropes/vasopressors agents for cardiogenic shock in situations with and without LVOT obstruction?
Randomized evidence to support an answer to this question is lacking. As the question recognizes, "cardiogenic shock" encompasses a diversity of anatomic and hemodynamic substrates of disease. Left ventricular outflow tract obstruction, which may be fixed or dynamic, a baseline feature or acutely ac...
Should thyroid hormone replacement be initiated in patients with very prolonged critical illness with associated low thyroid hormone levels?
There is no evidence that LT4 is of benefit in such patients.
What is your approach towards management of symptomatic broncholithiasis?
The broncholithiasis location relative to the airway can be outside the airway which is called peribronchial, inside the airway which is called endobronchial, or extends from inside to outside the bronchial wall which is called transbronchial broncholithiasis. Surgery is indicated in peribranchial b...
Do you use continuous or intermittent bronchodilator therapy in severe airway obstruction?
I use only intermittent.
What is your approach to monitoring for recovery in a patient with non-oliguric AKI requiring dialysis?
In my opinion, the best test to monitor the recovery of renal function in an AKI patient is a daily measurement of serum creatinine. Decreasing serum creatinine is the most reliable marker to indicate recovery of kidney function after AKI. The main confounder would be simultaneous loss of muscle mas...
Do you recommend using dextrose based solutions to induce osmotic diuresis for euvolemic patients with acute kidney injury in the setting of a hemolytic condition?
The incidence of hemolysis (especially after blood transfusion) has been so low that to my knowledge there have been no good studies about the treatment of AKI with osmotic diuretics in this setting. Older literature has always used Mannitol to induce osmotic diuresis, but whether that improved the ...