#389 SHM #Converge2023 Recap

April 16, 2023 | By Meredith Trubitt

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We recap the top pearls for the hospitalist from #SHM #Converge2023 covering discussions on syncope, heart failure, COPD, pneumonia, sickle cell pain management, nausea and dyspnea, complex pain management issues, delirium, geriatrics updates, severe infections from injection drug use, electrolyte management, perioperative anemia and anticoagulation, and GI updates. 

Note: Due to a rapid turnaround there is no CME for this episode, but visit curbsiders.vcuhealth.org to claim credit for past episodes.

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Show Segments

• Intro
• Picks of the Week
• Syncope
• Heart Failure
• Nausea and Dyspnea 
• COPD and Pneumonia
• Sickle Cell Pain Management
• Pain Management for the Hospitalist
• Delirium 
• Geriatrics Updates
• Electrolyte Management 
• Perioperative Anticoagulation
• Perioperative Anemia 
• Severe Infections from Injection Drug Use
• GI updates
• Outro

Syncope 

• Tongue biting is more specific for seizure compared to other exam findings we associate with seizure, such as urinary incontinence (Brigo, 2012). 
• Loss of consciousness associated with syncope can present with syncope as well (Brignole, 2018).
• PESIT trial: 17% of patients presenting with their first episode of syncope had a PE and two-thirds of those had a large vessel clot. 
• Canadian Syncope Risk Score – validated last year – (Zimmermann 2022, Thiruganasambandamoorthy 2020).

Heart Failure 

• No difference between torsemide and furosemide in all-cause mortality 12 months after discharge for acute heart failure exacerbation (Mentz 2023).
• Empagiflozin was shown to reduce the composite of cardiovascular mortality and heart failure hospitalizations in patients with HFpEF despite diabetes status. Notably the data is driven by reduction in hospitalizations (Anker 2021).

Nausea and Dyspnea

• Oxygen therapy in dyspnea without hypoxia is not helpful and can be harmful for the patient (Abernathy 2010, Chu 2018).
• Small meta-analysis reviewing bedside fans showed immediate improvement with dyspnea as an option for treatment of dyspnea during acute hospitalization (Yu 2018).
• Pulmonary rehab also offers benefits for symptomatic dyspnea at discharge (McCarthy, 2015).
• Small studies suggest low dose opioids can alleviate breathlessness symptoms (Bales 2016). Very low dose opioids (< 30 MMEs) are effective to alleviate symptoms (Ekstrom 2014). Benzodiazepines are associated with increased mortality in treating symptomatic dyspnea in end stage lung disease (Ekstrom 2014).
• Isopropyl alcohol for nausea relief compared to IV ondansetron was faster acting for post-op nausea relief (Winston 2003). 

COPD and Pneumonia 

• pH but not pCO2 is a good approximation across VBG and ABG (Watkins, 2022).
• Procalcitonin did not improve LOS and did not help to de-escalate care in acute COPD exacerbations (Chen 2020).
• Noninvasive ventilation is underutilized as treatment for COPD and hypercapnic respiratory failure despite good evidence that it reduces mortality and intubation need (Osadnik 2017).
• If not high risk for MRSA or GNRs, blood and sputum cultures are no longer recommended (Metlay, 2019).

Sickle Cell Pain Management 

• Distraction therapy may be part of the patient’s pain plan with their outpatient provider which means that sometimes they will be participating in activities that make them seem disinterested, but that is part of the therapy. This may require education to staff caring for the patient that this is part of their therapy (Brandow, 2020).
• Recommend engaging the outpatient sickle cell provider at time of admission.

Pain Management for the Hospitalist

• OPEN portal is a useful resource for opioid prescribing at time of discharge based on type of surgery/procedure someone had while admitted. 
• Low dose NSAIDs plus concomitant acetaminophen has NNT of 1.5 (to reduce pain score by 50%) so it can be a good option if not limited by possible adverse events (Moore 2015).
• Always treat for opioid use disorder in the hospital and ensure they are comfortable from both the withdrawal and the problem which brought them into the hospital (Raub 2017).

Delirium Updates

• 3D CAM based on DSM criteria has specificity of 94% and sensitivity of 95% for delirium (Marcantonio 2014).
• Early mobility in elderly patients looked at GPS monitors on elderly patients and showed only 43 minutes up and low (Brown, 2009).

Geriatrics Updates 

• Beers Criteria Update for 2022 is in process, but will likely strengthen recommendations made in the 2019 update including: use caution for rivaroxaban and warfarin; avoid sulfonylureas as a class of medications; limit PPIs for downstream risk of c diff, pneumonia, fractures, and renal impairment (www.americangeriatrics.org).
• USPSTF put up new recs for elderly patients that recommend against beta carotene, and insufficient evidence for MVI for prevention of cancer and heart disease (USPSTF, 2022).

Electrolyte Management

• Hypokalemia: 12% of patients will become hypoglycemic during insulin/dextrose delivery (Tran, 2020). Consider quality improvement opportunities to improve outcomes here.
• Hyperkalemia: Concern for bowel necrosis from sodium polystyrene does not have the best evidence  (Holleck, 2021).  As such and because it is a cheaper option, it can continue to be considered in patients with hyperkalemia.
• Utilize oral repletion over IV repletion whenever feasible due to oral repletion being significantly less expensive than IV. 

Perioperative Anticoagulation

• Per 2022 CHEST Guidelines: patients with mechanical valves who are coming in for elective surgery guidelines suggest against heparin bridging. However, it can be considered if select patients are at high risk for VTE and then may consider heparin bridging (Douketis 2022).
• In patients with VTE history and CKD there was less bleeding in apixaban over warfarin, but the study was unable to assess INRs in the warfarin group which could confound data (Cohen, 2022).
• In patients with afib and history of stroke who develop recurrent ischemic stroke while on DOAC there is no difference in recurrence of stroke if anticoagulant choice is switched. However, adding aspirin increases bleeding risk (Paciaroni 2022).

Hematologic Stewardship

• Replete nutritional deficiencies preoperatively as anemia is associated with increased mortality preoperatively (Warner, 2020).
• IR guidelines recommend that for low risk procedures including: catheter change, arterial interventions, venous interventions, HD access, spine injections, IVC filter, LP, chest tube, paracentesis, thoracentesis, abscess drain, and transjugular liver biopsy, there is no need to check INR/PTT or CBC, but if it was already done, above procedures are safe if INR < 2-3 and platelets > 20 (Patel, 2019).

Severe Infections from Injection Drug Use

• Treat opioid use disorder concomitantly with the patient’s underlying infection
• Transitions of care: decreasing a patient’s tolerance to opioids during acute hospital stay has an increased risk of overdose immediately after discharge (Lewer, Eastwood et al 2021). 
• Counsel patients on risk of overdose. If they plan to use it when they leave, they should start low and go slow because their tolerance has changed. Ensure necessary harm reduction tactics including naloxone in hand at time of discharge. For more harm reduction references, check out harmreduction.org.

GI updates 

• For acute pancreatitis, aggressive volume repletion arm led to increased volume overload (de Madeira, 2022).
• Elastography can be used to determine if patient needs EGD evaluation for variceal bleed assessment in patients with cirrhosis (Gralnek, 2022).

Links

1. Torchy’s Tacos 

Goal

Listeners will be served delicious knowledge food from SHM’s #Converge2023.

Learning objectives

After listening to this episode listeners will…  

1. Review key practice-changing pearls

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Sensabaugh C, Trubitt M, Amin, M. “#389 #SHM #Converge2023 Recap”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date April 10, 2023.