Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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.
Do you routinely continue using TPA/Dornase for treatment of empyema, if there is accumulation of new sero-sanguinous output from the chest tube after the initial treatment?
In my practice, if there is an accumulation of serosanguinous output after initial treatment, further treatment with tPa/ dornase depends on several factors. Hct of drainage - if > 50%, will not give further dose. If a patient is coagulopathic or receiving anticoagulation for a medical condition af...
Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?
In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful o...
Do you proceed with outpatient hemodialysis for an asymptomatic ESKD patient who has missed the last three hemodialysis sessions?
In the ideal world, missing too many HD sessions (no magical number) can predispose patients to quick normalization of low Na or very high BUN which we don’t want to! Also, asymptomatic patients don’t mean okay volume, patients' BP might be as high as 200s and this needs extra sessions to get back t...
Do you prefer that hospitalized peritoneal dialysis patients use their own home dialysis equipment during the admission?
At our hospital, where we have our own PD equipment and RNs on call to set it up, we strongly prefer that patients DO NOT use their personal equipment. Liability concerns, but this approach won't work in a hospital where that backup does not exist. If the patient's choice is to have a TDC placed for...
What is your approach to the use of intravenous sodium thiosulfate for the management of calciphylaxis in a patient with end stage kidney disease and on hemodialysis?
We have sodium thiosulfate 25gm IV each dialysis given during the last hour of treatment as a standard order in our dialysis order set. We have seen a useful response in some patients after several weeks, but there are no clear trial-based data to support the use of this treatment. I would certainly...
What is your preferred strategy for controlling bleeding after transbronchial or endobronchial biopsies?
I use all Cold Saline, Wedging and EPI. If severe bleeding side down, therapeutic bronchoscope with suctioning blood till bleeding stops. Also to assess bleeding risk prior (low PLT, hx of ASA anticoagulation use) to bronchoscopy and during bronch watching oozing and stopping further biopsy can be v...