Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you start steroid therapy in a patient with pure ARDS without septic shock, or would you only consider steroids only in those with severe community acquired pneumonia?
I do not routinely start corticosteroids for pure ARDS, septic shock, or severe community-acquired pneumonia. In my mind, the DEXA-ARDS study was underpowered to answer the question. The recently published ESCAPE and CAPE-COD trials yielded conflicting results in CAP. In my mind, before adopting cor...
Would you recommend initiating RRT in a patient with tumor lysis syndrome and a phosphorus of 9 mg/dl or more who does not have symptomatic hypocalcemia or other indications for dialysis?
If the patient is urinating and maintaining a urine output with IV NS, and if there is no other indication for dialysis, then one can argue that the risks of RRT (catheter insertion and infection) outweigh any benefits.
How often and when do you consider trending NT-proBNP levels for patients with HFrEF admitted for acute decompensated heart failure?
NT-proBNP would normally be assessed upon admission for acute decompensated heart failure, and this is a Class 1 recommendation in the 2022 HF guidelines. I do not routinely re-check or trend NT-proBNP during the hospitalization until immediately prior to discharge. However, a predischarge NT-proBNP...
Have you encountered acute kidney injury after starting eltrombopag for aplastic anemia as part of triple immunosuppressive regimen with ATG and cyclosporine?
No, I have not. Of course, cyclosporine is intrinsically nephrotoxic and is the likely candidate. Sometimes, ATG will result in renal issues as well although less frequently.
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.