HM12's Clinical Pearls
Although bedside procedures have long been a staple of internal-medicine practice, the field of procedural medicine has increasingly become the domain of hospitalists, many of whom call themselves proceduralists. Nearly all procedures can be aided by ultrasound guidance, and for many procedures, ultrasound guidance is the standard of care.
KEY TAKEAWAYS
- Performing bedside procedures safely requires specific training and steady experience that is well-suited to healthcare providers in hospital medicine.
- Ultrasound guidance is considered the standard of care for central venous catheter placement, paracentesis, and thoracentesis.
- Widely accepted limitations in fluid removal thought to prevent re-expansion pulmonary edema (RPE) after thoracentesis might not prove to be valid.
- Arbitrary cutoffs for INR and platelet count in paracentesis are based on data that might not be valid in bedside paracentesis.
- Use of non-traumatic lumbar puncture needles, such as the Gertie-Marx and Sprotte needles, may reduce the incidence of post-LP headache.
- Fine-needle aspiration, punch skin biopsy, and arthrocentesis are bedside procedures that can be mastered by hospitalists and used regularly in their practices.
- Establishing a proceduralist group or center initially requires showing to hospital administrators benefits other than revenue, such as reduction in CLABSIs and off-loading other procedural services.
A program that is structured in such a way as to hire or retain experienced hospitalists is likely to have a higher cost savings than one that doesn't.
—Weijen Chang, MD, SFHM, pediatric hospitalist, University of San Diego Medical Center and Rady Children’s Hospital in San Diego
SESSION
ACCP Antithrombotic Therapy Guideline: The Questions that Remain Unanswered
Daniel Brotman, MD, FACP, FHM, of Johns Hopkins University School of Medicine in Baltimore addressed questions all hospitalists wonder about: Is warfarin still the best anticoagulant in atrial fibrillation (afib)?; Should DVT prevention extend beyond hospitalization?; When should anticoagulation be started in stroke patients with afib?
Warfarin, Dr. Brotman explained, has many disadvantages, and new oral anticoagulants (e.g. dabigatran, apixaban, rivaoxaban) offer many advantages with lower side-effect profiles. All of the new agents appear to have either better efficacy or trend toward better efficacy; none require monitoring, and all have lower rates of ICH.
Prices are higher for new agents but are competitive with other drugs currently on the market for other diseases. Use dabigatran with caution in patients with renal failure, and realize that there is no antidote for any of these drugs. Dabigatran is acidic and causes gastrointestinal (GI) upset, thus has a higher rate of GI bleeding. Stop any of these five days prior to planned procedures, longer if patients are at high risk of bleeding.
Evidence from RCTs in hospitalized surgical patients suggests that VTE prophylaxis should be continued in patients undergoing hip surgery and surgery for abdominal or pelvic malignancy. Patients admitted for acute medical illness do not benefit from VTE prophylaxis beyond acute hospitalization, even if immobilized, unless they have solid tumors with additional risk factors (hormone use, prior VTE, etc.) and are at low risk for bleeding. Chronically immobilized patients do not benefit from VTE prophylaxis beyond the acute hospitalization.
Oral anticoagulants can be started within one to two weeks of stroke onset. The larger the stroke, the greater the risk of hemorrhagic transformation with early anticoagulation, so the smaller the stroke, the safer it is to start early. VTE prophylaxis is important regardless.
KEY TAKEAWAYS
- We’ll be using the new oral anticoagulants in place of warfarin in the coming years, although there is no safe anticoagulant. Be cautious and aware of the side-effect profiles of each.
- Don’t sweat VTE prophylaxis in chronically immobilized patients unless they are acutely hospitalized.
- VTE prophylaxis is critical in stroke patients, but the larger the stroke in afib patients, the longer the wait to start oral anticoagulation.
A program that is structured in such a way as to hire or retain experienced hospitalists is likely to have a higher cost savings than one that doesn't.
—Caitlin Foxley, MD, FHM, medical director of Inpatient Management Inc., Nebraska Medical Center Hospitals, Omaha
