SHM 2010 Day #2 "Hospitalists...the 2010 National Champions"

Plenary Session
The plenary session started with the winners of the abstracts for this year, that asked the following questions:
Does hospitalist care change one year post discharge increase readmission or use of health care resources? Actually decrease in any emergency department visits but not frequency, if they start going to the emergency department they keep going. Also decreases MD office visits, but no difference in post-discharge hospitalization. The researchers hypothesized that hospitalists have an increased use of home health

What does disclosure do to liability? i.e. what is the effect of transparency?
Yes it improves (decreases) claims, time to resolution with a 53% decrease in liability costs

The final presentation was an innovation in health care, in this case ensuring safe discharge of homeless patients using a respite program. Which of course begs the question if respite programs might be used for patients with homes to decrease readmissions.

NIPPV in acute respiratory failure
Inspiration actually places inward pressure on external airways while internal airways expand. Examining the hysteresis curve at the ends where maximal changes in pressure have minimal changes in volume is comparable to filling a balloon, the most difficulty is at the beginning and end of filling of the balloon.

Positive pressure ventilation

• Decreases venous return
  
• Decreases RV stroke volume and increases LV filling volume
  
• Decreases work of breathing
  
• Improves gas exchange
  
• Unloads heart
  

CPAP improves oxygenation
PSV improves ventilation
BiPAP = CPAP + PSV

Entry criteria

• Able to protect airway (anatomic + neurologic)
  
• Stable hemodynamics
  
• Absence of MSOF
  
• Cooperate with NIPPV
  
• Compatable facial anatomy
  
• Can tolerate insuflation
  

NPPV Predictor of Success

• Youth
  
• Low APACHE score
  
• Cooperative
  
• Moderate hypercarbia, PaCO2 > 45 mmHg
  
• Mild acidosis
  

NPPV in COPD (Cochrane Database Syst Rev. 2004;(3):CD004104)

• PaCO2 > 45 mmHg
  
• Decreased mortality and LOS
  
• Works well for modern COPD exacerbations
  

NPPV in decompensated left heart failure

• Decreased ICU admissions, if started in ED
  
• 50% reduction in need to intubate
  
• Widely accepted for ADHF
  
• If PaCO2 normal use CPAP not BiPAP
  

Other indications of NPPV

• Immune compromised patients (Intensive Care Med. 2002 Sep;28(9):1233-8)
  
• Hypoxemic respiratory failure (Crit Care Med. 2004 Dec;32(12):2516-23)
  
• Pneumonia with manageable secretions
  
• Asthma exacerbation (Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004360)
  

Clinical pearl: Status asthmaticus with normal ABG is either not that sick or about to crash.

Preoxygenation before intubation
Am J Respir Crit Care Med. 2006 Jul 15;174(2):171-7
Critically ill patients have ~30 seconds before they become hypoxic versus nearly 5 minutes in healthy adults. Effective bag mask ventilation is difficult, thus BiPAP studied before intubation: higher preintubation SpO2, smaller dip in SpO2, fewer severe desaturations.

Postextubation Respiratory Failure
N Engl J Med. 2004 Jun 10;350(24):2452-60
NPPV is an effective bridge post extubation far longer before reintubation. NPPV prevented reintubation only if instituted BEFORE the onset of respiratory failure.

Airway Obstruction?
Sometimes if rapidly reversible cause NPPV can "stent" open an airway

Initiation

• Early is Better (Intensive Care Med. 2002 Dec;28(12):1701-7)
  
• Moderate severe respiratory distress
  
• pH < 7.35 and PaCO2 > 45 mmHg
  
• RR > 25
  

How do I know if it's working?
Chest. 2000 Mar;117(3):828-33

• pH, PaCO2, and LOC if these do not improve in 1-2 hours, it will probably not improve
  
• 48-72 hours total trial
  

Mask Type

• Face mask is more effective
  
• Nasal mask/pillows are more comfortable
  

Complications

• Discomfort
  
• assure: rjuy to nose, the. eye
  
• sinus pain/congestion
  
• mild gastric distortion
  
• Barotrauma is uncommon
  
• Adverse hemodynamic reactions uncommon
  

Common Hematologic Emergencies and Consults
Thrombocytopenia, defined as platelets < 150000

Causes

• Artefact
  
• Dilution
  
• Sequestration
  
• Decreased production
  
• Increased consumption
  

Essentials of work-up

• Review blood smear
  
• History of blood transfusions
  
• Hypersplenism
  
• Bone marrow biopsy
  

"Washout phenomenon"
Platelet count < 50000 would be equivalent to about 15 units transfused

Congenital hereditary thrombocytopenia
Bleeding out of proportion to platelet count and often associated with platelet function deficit (gray platelets, Bernard-Soullier, vWF deficiency Type 2B)

May Hegglin Anamoly
Diagnosed by peripheral smear and associated with MYH9 mutation

Other causes of thrombocytopenia

• B-12 deficiency
  
• Alcohol abuse
  
• Leukemia
  
• DIC
  
• ITP
  
• TTP/HUS
  

Drug-induced thrombocytopenia
Heparin-induced thrombocytopenia (Chest. 2005 Feb;127(2 Suppl):35S-45S)
Diagnostic gold standard: Serotonin platelet loaded assay, however platelet factor 4 assay more commonly available. Hospitalist should support and promote efforts to eliminate heparin flushes. HIT can cause both arterial and venous thrombosis. Fondaparinux can be used to treat (unlabelled use).

Platelet GP IIb-IIIa inhibitors may cause sudden severe drop in platelets (N Engl J Med. 2004 Jan 15;350(3):232-8)

Idiopathic Thrombocytopenic Purpura
Increased bone marrow megakaryocytes. Thrombocytopenia + mucosal based bleeding have increased chance of intracerebral hemorrhage. RFVIIa limits ICH volume in ITP.
Treatment

• 2/3 corticosteroids
  
• 2/3 IV Ig
  
• 2/3 anti-D immunoglobulin (may cause DIC in elderly patients)
  
• 2/3 splenectomy
  
• 2/3 danazol (associated with some virilization and increased hepatic dysfunction
  
• TPO mimetics increase megakaryocyte production of platelets

?H. pylori positive associated with ITP more true in Asia than the US

Thrombotic Thrombocytopenic Purpura
The classic pentad of microangiopathic hemolytic amenia, neurological abnormalities, fever, renal failure and thrombocytopenia is nearly useless clinically. Instead:

• Schistocytes
  
• Elevated LDH
  
• ADAMTS13 inhibitor
  
• vWF multimers
  
• No anticoagulation abnormalities and negative D-dimer
  

Treatment is plasma exchange and corticosteroids

Disseminated intravascular coagulation
Too much thrombin generation or too little down regulation in thrombin or points along the cascade. Induced by sources of tissue factor and is an acquired syndrome characterized by intravascular activation of coagulation leading to end organ damage. Associated with sepsis, trauma, malignancy, obstetric complications, vascular disorders, toxins (snake bite), and immune disorders (severe allergic reactions or transplant rejection). Treatment:

• Treat the underling cause
  
• Heparin anticoagulation
  
• Platelet transfer after anticoagulation
  
•  FFP/cryoprecipitate
  
• ATIII concentrate
  
• Activated protein C concentrate
  

Antiphospholipid Ab syndrome
J Thromb Haemost. 2006 Feb;4(2):295-306
Think of this diagnosis in a pregnant woman presenting with stroke and has a history of recurrent spontaneous abortions. These patients must be anticoagulated, bridge with heparin, eventually target INR > 2.5 with warfarin. If recurrent thrombosis add aspirin.

VTE and postthrombotic syndrome
Deep vein thrombosis is 15-25% associated with cancer and carries 7% mortality. Thrombolytic therapy has not been shown to improve overall mortality.