Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?
Yes, I do. In my experience, nephrologists tend to forget or neglect the use of HCQ. HCQ can prevent lupus flare-ups and progression of disease not to mention CV benefits as well as being helpful in addressing APS if present.
What is your preferred agent and duration to treat an epidural abscess due to azole-resistant candida species?
I would treat it like osteo, e.g., 9-12 months.
Would bag-mask ventilation with a PEEP valve be a reasonable alternative to NIV for pre-oxygenation prior to intubation in settings where NIV is not easily accessible?
The PREOXI trial does not inform the use of a bag-mask device with a PEEP valve. Many invasive mechanical ventilators are capable of delivering noninvasive ventilation using the same mask that the bag-mask device uses.
How do you identify which patients are at highest risk for decompensation and most likely to benefit from NIV for pre-oxygenation prior to intubation?
This study was a multicenter, randomized trial that included 1,301 patients from 24 emergency departments and intensive care units. Patients were assigned to receive preoxygenation either with NIV or an oxygen mask. The study found that there was significantly less hypoxemia in the NIV group. Cardia...
Is there a subset of patients in whom pre-oxygenation with NRB or BVM could be safely pursued?
Preoxygenation using an oxygen mask that does not provide positive pressure may be appropriate in patients who have a contraindication to noninvasive ventilation such as patients with active emesis. However, one of the key findings of the PREOXI trial was that preoxygenation with noninvasive ventila...
Does the experience level of the intubation operator affect outcomes related to pre-oxygenation with NIV versus an oxygen mask?
Operator experience is certainly associated with first-pass success rate and time from induction of anesthesia to intubation, but this is not an interaction we specifically looked for in PREOXI. I will speculate along with you that since NIV improves pre-oxygenation and prolongs the time until desat...
What are the logistical challenges and time constraints of implementing NIV for pre-oxygenation in emergency settings compared to oxygen masks?
Logistical and training challenges do exist to routine implementation of noninvasive preoxygenation. Perhaps the most challenging one is the availiability of the mechanical ventilator in the emergency setting at the time of intubation. In settings where mechanical ventilators are not routinely prese...
Does the use of NIV for pre-oxygenation delay the time to intubation?
That probably depends on how you define "time to intubation". In the study, we measured time from induction of anesthesia to intubation and % of successful intubations on the first attempt, which were nearly identical between groups (Table 3). However, I suspect the real question is whether NIV preo...
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...
How does premorbid dementia affect your decision to offer acute stroke intervention?
Receiving a report on an acute stroke patient with "dementia" often feels like an umbrella term and, in my experience, tends to serve more as a label than an accurate reflection of their baseline cognitive function. Ideally, having enough clinical information to classify cognitive impairment as mild...