#485: Things We Do For No Reason™Live from SHM #Converge2025

June 2, 2025 | By Monee Amin

Audio

Video

Transcript available via YouTube

Brush up on your high-value care by exploring four Things We Do For No Reason with experts Dr. Tony Breu (@tony_breu, Harvard University) and Dr. Lenny Feldman (@DocLennyF, Johns Hopkins University). Follow along as they explore lactate-guided resuscitation in shock, beta blocker use with cocaine, holding anticoagulation in patients with fall risk, and discharge before noon.

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Show Segments

• Intro
• Picks of the Week
• Part 1: Things We Do for No Reason™: Using lactate as our resuscitation guide in sepsis
• Part 2: Things We Do for No Reason™: Discontinuing β-blockers in patients who use cocaine
• Part 3: Things We Do for No Reason™: Discontinuing anticoagulation in older patients with atrial fibrillation and a high risk of falls
• Part 4: Things We Do for No Reason™: Discharge before noon
• Outro

Disclosures

Dr. Breu and Dr Feldman report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Things We Do For No Reason at SHM Converge 2025 Pearls

1. Lactate does not equate to tissue hypoperfusion in sepsis, but rather is more synonymous to beta-2 activation.
2. Do not fear the beta blocker in patients who use cocaine. 
3. Calculate the risk of ischemic stroke and risk of falls and risk of bleeding associated with the fall. Do not be afraid of continuing the anticoagulation in patients at risk for falls, but can look for ways to mitigate risk of falls instead. 
4. There are conflicting interests of multiple stakeholders involved in discharge before noon metrics. 

Things We Do For No Reason™ at SHM #Converge2025 – Notes

Part 1: Things We Do for No Reason™: Using lactate as our resuscitation guide in sepsis

• The heuristic that exists is that lactate elevation = tissue hypoxemia. 
• However, when measured at altitude where tissue hypoxemia are known, lactate remains relatively stable (Reeves, 1992). 
• When thinking about this at the cellular level, when there is excess pyruvate and the cell cannot make infinite ATP, this leads to the overproduction of lactate. And the most common pathway to lead to overproduction of pyruvate is actually beta 2 activation (Levy, 2008).
• Use lactate to aid in the risk stratification of patients with sepsis: patients with an elevated lactate that does not clear by 20% after initial resuscitation have a poorer prognosis and require closer monitoring.
• Do not use lactate in isolation as a marker for the ongoing need for resuscitation–instead, employ an individualized treatment plan using clinical findings, such as capillary refill test or passive leg raise, with lactate and other biomarkers to drive the use of intravenous fluids or other pharmacologic interventions.

Part 2: Things We Do for No Reason™: Discontinuing β-blockers in patients who use cocaine

• Hospitalists worry that β-blocker use with cocaine use will lead to unopposed α‐stimulation, which may worsen hypertension and coronary artery vasoconstriction.
• This is based on a 1990 study by Lange and colleagues, which has been frequently cited in support of withholding β‐blocker therapy (Lange, 1990). In this very small randomized controlled trial, 30 patients undergoing cardiac catheterization received either intranasal saline (n = 15) or hospital-grade cocaine (n = 15), which is not representative of the cocaine modern-age patients are using. After the cocaine or saline administration, the patients had intracoronary propranolol infused, which is neither physiologically representative of how patients use beta blockers, nor is it typical for most patients to be on a non-selective beta blocker like propranolol. Nonetheless,   hemodynamic measures such as mean arterial pressure, coronary vascular resistance, and myocardial oxygen demand increased with cocaine administration. 
• However, more recent studies demonstrate that patients treated with β‐blockers in the setting of cocaine use have comparable or improved rates of myocardial infarction, arrhythmia, hospital length of stay, and all‐cause mortality. These studies also used more physiologic administration of beta blockers such as IV labetalol, compared to intracoronary administration of propranolol in the original Lange 1990 paper (Boehrer, 1993; Rangel, 2010, Lo 2018).
• It is recommended to continue chronic beta blocker therapy for patients with cocaine use when indicated for a comorbidity, and resume beta blockers that have been held in patients with cocaine use due to fear of unopposed α‐stimulation.

Part 3: Things We Do for No Reason™: Discontinuing anticoagulation in older patients with atrial fibrillation and a high risk of falls

• In older patients with atrial fibrillation, the benefits of anticoagulation (AC) for stroke prevention outweigh the bleeding risks. Although a significant association between intracranial hemorrhage and fall risk exists, current evidence indicates AC therapy reduces cardiovascular mortality, including ischemic stroke, in older patients who have a high fall risk and a moderate to high risk for stroke (Hendricks, 2020).
• A Markov decision analytic model estimates an individual would have to fall 35 times per year for the risk of intracranial hemorrhage to outweigh the benefit of ischemic stroke prevention for an individual on warfarin (Man-Son-Hing, 1999). Similar modeling estimates an older adult on apixaban would have to fall 458 times per year for risk to outweigh benefit (Wei, 2021). 
• Do not use fall risk alone as a reason to withhold or discontinue AC from older adults with AF. Consider using stroke risk calculators (Atria Stroke Risk Score, CHA₂DS₂-VASc Score for Atrial Fibrillation Stroke Risk) and bleeding risk calculators (HAS‐BLED, ORBIT, DOAC score, GARFIELD-AF, Atria Bleeding Risk Score) to determine the risk‐benefit profile of continuing AC. 
• Speak with the patient and their family and have shared decision‐making regarding balancing the benefits of stroke prevention against bleeding risk. Mitigate the risk of future falls by referring to evidence‐based fall prevention therapy programs and home safety evaluations, or by medically managing predisposing risk factors like alcohol use disorder.
• Don’t substitute aspirin for AC to mitigate bleeding risk. Aspirin has no role in preventing stroke in atrial fibrillation, and should not be used as an alternative to therapeutic AC.

Part 4: Things We Do for No Reason™: Discharge before noon

• Before discussing discharge before noon, it is paramount to identify which metric hospitals are trying to improve like decreased emergency department boarding time, as well as balancing metrics like total length of stay and provider satisfaction to ensure other metrics are not falling behind during the intervention.
• Much of the evidence supporting discharge before noon is either single center and/or limited by confounding bias.
• Individual providers should focus on discharging patients based on individualized assessment of when they are medically ready to leave, and advocating for systems‐level changes to facilitate improved hospital flow.

Links

1. The Punk Rock Museum
2. David Copperfield

Goal

Listeners will develop a familiarity with how using a lactate to guide resuscitation in shock, avoiding beta blockers in patients who use cocaine, holding or discontinuing anticoagulation in all patients at risk for falls, and discharge before noon are all Things We Do For No Reason.

Learning objectives

After listening to this episode listeners will:

1. Identify why lactate is not an appropriate sole marker to guide resuscitation in shock.
2. Distill why beta blockers are not contraindicated in patients with current or past cocaine use.
3. Review why discontinuing anticoagulation in patients with atrial fibrillation may cause more harm than good.
4. Explore why discharge before noon is an unhelpful metric for patient flow and length of stay.

Citation

Coleman C, Amin, M, Trubitt M, Breu T, Feldman L, Williams PN, Watto MF. “#485 Things We Do For No Reason™ Live from SHM #Converge2025”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast June 2, 2025.