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DVT Prophylaxis: Don’t Forget the Pediatric Patients

Most would agree that hospitalists have seen more thrombosis in children over the past decade, and although it isn’t known why, it is likely due to multifactorial causes, said Leslie Raffini, MD, MSCE, director of the Hemostasis and Thrombosis Center at Children’s Hospital of Philadelphia.

Central venous catheters remain a significant risk factor for venous thromboembolism (VTE), and our knowledge of inherited risk factors has expanded in recent years. While it is likely that inherited risk factors increase the risk of thrombosis in children, the question of testing has engendered debate, due in large part to the lack of clear benefit of that information in the majority of situations.

“The decision to test should be made on an individual basis, after counseling,” said Dr. Raffini. “Results should be interpreted by an experienced physician with adolescent females most likely to benefit from the testing. There are no recommendations for what to do with pediatric patients” despite the fact that this is an important cause of morbidity in high-risk patients.

Dr. Raffini described efforts at Children’s Hospital of Philadelphia that led to a VTE prophylaxis guideline. Successful implementation of the guideline required significant multidisciplinary collaboration, and an analysis of outcomes is under way.

KEY TAKEAWAYS

The decision to test for inherited risk factors should be individualized.

Adolescent females are most likely to benefit from testing for inherited risk factors.

Implementation of guidelines requires intentional multidisciplinary collaboration.

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.

—Mark Shen, MD, SFHM, FAAP, medical director of hospital medicine, assistant professor of pediatrics, Dell Children’s Medical Center, Austin, Texas

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Updates from the 9th ACCP Antithrombotic Therapy Guidelines

The evidence-based, rapid-fire presentation by Catherine Curley, MD, of MetroHealth Medical Center in Cleveland on the brand-new antithrombotic therapy from the ACCP took attendees through key aspects of the new guidelines. Dr. Curley used the more controversial topics as examples: treatment of submassive PE, use of catheter-directed thrombolysis in patients with acute DVT, recommended VTE prophylaxis. She even threw in some anatomy lessons for clinicians.

KEY TAKEAWAYS

Major innovations in the methodology in the AT9: Focusing on the absolute effects to allow the provider to weigh the benefits and risks of therapy easily; rigorous conflict-of-interest reviews of the editors; re-analysis of many older studies; and simplified recommendations with emphasis on summary-of-finding tables as opposed to texts.

A strong focus on patient-centered outcomes recommends specifically focusing on patients’ preferences.

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.

—Larry W. Holder, MD, FACP, FHM, medical director of hospitalist services, chief medical information officer, Decatur (Ill.) Memorial Hospital

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HM12 Pre-Course: Medical Procedures for the Hospitalist

Bradley Rosen, MD, MBA, FHM, of Cedars Sinai Medical Center in Los Angeles, Sally Wang, MD, FHM, of Brigham and Women’s Hospital’s in Boston, and Joshua Lenchus, DO, RPh, SFHM, of the University of Miami Miller School of Medicine led a motivated group of hospitalists through hands-on training in bedside invasive procedures during two half-day pre-course sessions at HM12. With emphasis on ultrasound guidance and evidence-based practices, the faculty provided the sold-out audience with lively discussions and small-group experiential education in central venous catheter placement, paracentesis, thoracentsis, lumbar puncture (LP), and other bedside procedures.

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

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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

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Update in Hospital Medicine

Facing a packed house in the main auditorium, Kevin O’Leary, MD, of Northwestern University’s Feinberg School of Medicine in Chicago and Efren Manjarrez, MD, from the University of Miami’s Miller School of Medicine synthesized dozens of research articles that are clinically relevant to hospitalists everywhere. “We looked for articles that would change or modify your current practice,” Dr. O’Leary said.

KEY TAKEAWAYS

Regarding optimal diuretic dosing strategy in patients hospitalized with acute heart failure: While there was no difference between IV bolus versus continuous infusion of diuretics in the primary outcome of global symptoms or change in creatinine, patients treated with a dose 2.5 times their home dose saw significant improvement in their global symptoms, but it came at the expense of a significant increase in creatinine.

VTE prophylaxis is routinely used in all medical and stroke patients without a clear understanding of the benefits and harms for each patient, and hospitalists should make individual VTE prophylaxis decisions for each patient.

New options for anticoagulation in atrial fibrillation: While rivaroxiban and dabigatran were both found to be non-inferior to warfarin in the prevention of stroke and systemic emboli and in major bleeding complications, only apixiban was found to have a statistically significant improvement over warfarin.

Identifying risk of perioperative cardiac death or non-fatal MI after surgery: The use of BNP along with the Revised Cardiac Risk Index improved the risk stratification of patients by achieving better separation between low-, intermediate-, and high-risk patients.

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.

—Michelle Mourad, MD, director for quality, division of hospital medicine; assistant professor, department of medicine, University of California at San Francisco Medical Center

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Complicated Pneumonia and Acute Hematogenous Osteomyelitis: New Insights into Diagnosis and Management

The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to Vanderbilt University School of Medicine’s Derek Williams, MD, MPH, and C. Buddy Creech, MD, MPH, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.

The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas, including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.

Osteomyelitis might be caused by direct inoculation, spread from local infection, or hematogenous spread. S. aureus is a causative agent in 80% to 90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics might be appropriate.

KEY TAKEAWAYS

Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.

Hematogenous spread is the most common cause of osteomyelitis in children.

MRI is the diagnostic modality of choice for osteomyelitis.

Bone aspiration and blood cultures are very helpful in the treatment of osteomyelitis.

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.—Dan Hale, MD, FAAP, pediatric hospitalist, Floating Hospital for Children at Tufts Medical Center, Boston

HM12's Clinical Pearls