Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In massive transfusion protocol from suspected hemorrhage, is it worth obtaining a TEG to guide transfusion?
There really is no evidence (except expert opinion) on massive transfusion protocols and outcomes. There are a few trials showing that TEG or other viscoelastic tests reduce transfusion and even improve survival or other important outcomes in hemorrhage. So given the choice, if rapid point of care T...
Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?
I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs ...
How do you manage hemodialysis for an ESKD patient presenting with severe hyponatremia and a serum sodium more than 10 mEq/L below the lowest available dialysate sodium concentration?
There are multiple ways of dealing with this situation. One option is not to dialyze if not urgent and let the sodium come up before starting dialysis. The most exact way of dealing with the situation is to do hemofiltration either continuously or intermittently with a concomitant D5W infusion adjus...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
How do you decide if patients without contraindications should receive IV fluids during the pre-operative period if they are undergoing surgery during their hospitalization?
I agree with Dr. @Dr. First Last. Volume status determination remains subjective, and a combination of urine output (and color!), physical exam, patient history, and vital sign review often provides conflicting information requiring subtle interpretation. Hypervolemia leading to pulmonary edema will...
Do you treat Stenotrophomonas maltophilia bacteremia with combination therapy and if so, what is your preferred combination of antibacterials?
Yes, I would use two agents, at least up front, as recommended in the 2024 IDSA guidelines (Tamma et al, PMID 39108079). The guidelines suggest two of the following agents should be used, unless the combination of ceftazidime-avibactam plus aztreonam is used instead: cefiderocol, TMP/SMX, levofloxac...