Update in Hospital Medicine 2017 - Dalhousie University · 2020-06-11 · Pollack CV Jr,et al N...
Transcript of Update in Hospital Medicine 2017 - Dalhousie University · 2020-06-11 · Pollack CV Jr,et al N...
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Update in Hospital Medicine 2017
Elizabeth Burton, MD, CCFP
Hospitalist, QE II Health Science Centre,
Halifax, NS
September 30, 2017
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15th Annual
Canadian Society of Hospital Medicine
Faculty/Presenter Disclosure:
• Faculty: Elizabeth Burton
• No Relationships with commercial interests
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Methodology
• Journal search:
• NEJM
• Annals of Internal Medicine
• JAMA/ JAMA Internal Medicine
• BMJ
• Lancet
• The Hospitalist
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Case 1
Ms. GI
• 56 year old female with epigastric pain, nausea,
vomiting with gradual onset over 24 hours. Now
unbearable, 9/10 constant pain. No coffee grind
emesis, no melena
• PMH: Generally well, Obesity, no home meds. No
previous surgery
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• Vitals: Temp 37.5, HR 88, BP 152/88, RR 18, O2 sat 94%RA
• Physical exam:
• Normal cardiorespiratory exam. Tender epigastrium. No edema. No
Stigmata of Liver disease
• Labs:
• WBC 12, Hgb 148, Lipase 2300, ALT 58, AST 44, Bili 10, trop <14, Cr 80,
Urea 11, Electrolytes within normal, CRP 120
• ECG: normal sinus rhythm
• Imaging:
• CXR: no acute abnormality
• Abdo US: no cholecystitis, no biliary tract dilation
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Ms. GI is admitted with acute pancreatitis: NPO, high
rate IVF, parentral pain and nausea control.
• Dietician approaches you the next day and asks
what do want to do with her diet?
A. Continue NPO
B. Feed her
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Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic
Review.
Vaughn VM, et al.
Ann Intern Med. 2017;166(12):883. Epub 2017 May 16.
• Systematic review looking at early (<48 hours) or late (>48 hours) feeding in acute
pancreatitis.
• Outcomes:
• Primary: LOS, mortality, readmission
• Secondary: feeding tolerance, N/V/abdo pain, necrotizing pancreatitis
• Extracted data and rated bias in studies
• Of 1319 citations reviewed:
• 11 RCTs including 948 patients
• 7 trials (3 low risk of bias) mild-moderate pancreatitis
• 4 trials (1 low risk of bias) severe pancreatitis
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Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic
Review.
Vaughn VM, et al.
Ann Intern Med. 2017;166(12):883. Epub 2017 May 16.
• Heterogenous feeding protocols (PO, NG, Nasojejunal)
• No studies showed significant increase in adverse effects or worsening
symptoms, regardless of severity with early feeding
• Mild-moderate pancreatitis:
• 4 studies (including 2 with low risk bias): reduced LOS with early feeding
• 3 studies (including 1 with low risk bias): reduced feeding
intolerance/n/v/abdo pain with early feeding
• Severe pancreatitis:
• 1 study (low risk bias): no difference LOS, mortality, symptoms
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• Conclusions:
• No harm and possible benefit to start feeds within
48 hours of admission for mild-moderate
pancreatitis
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Severity in Pancreatitis
• On admission:
• APACHEII: calculator
• SIRS criteria: at least 2 of:
1) Temp >38.3 or <36,
2) HR >90,
3)RR >20 or PaCO2 <32,
4)WBC >12 or <4 or >10% bands
• At 48 hours:
• Ranson: calculator
• CRP: cut off 150
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Ms. GI:
• No SIRS criteria
• Mild acute pancreatitis
• Would consider early feeding within 48 hours of
admission
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Case 2Mr. PE
• 77 year old male presented with “fall” with LOC<1min. No CP,
SOB or Abdo pain. Right knee and leg is swollen and sore.
• PMH: MCI, alcohol use disorder, smoker, ?COPD,
hypertension
• Vitals:
• 88/50>>100/60 post fluid
• HR 115>>105 post fluid
• RR 24
• O2 sat 88% room air
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• Physical Exam
• Normal cardiac/respiratory/abdominal exam. No focal neurologic
finding, mild swelling right lateral knee and lower leg. Good ROM
knee
• Labs
• Cr 76, WBC 11, Hgb 110, lytes within normal, trop <14, ABG: mild
hypoxia
• CXR: normal
• Right knee X-ray: no fracture
• ECG: sinus tachycardia, no ST changes, no heart block
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• Admitting doctor stops BP meds and admits with
Falls NYD, likely related to iatrogenic hypotension,
alcohol use +/- something else
• Question: Is there any other important work-up or
diagnoses you would consider in this gentleman
with syncope?
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Prevalence of Pulmonary Embolism among Patients Hospitalized for SyncopePaolo Prandoni, et al, for the PESIT Investigators*
N Engl J Med 2016; 375:1524-1531October 20, 2016DOI: 10.1056/NEJMoa1602172
• 11 Italian hospitals, first episode syncope (regardless if other explanations of
syncope)
• Ruled out if:
1) Negative Wells Score (4 or less) AND
2) Negative D-dimer
• If not ruled out had CT-PE protocol or V/Q scan or autopsy
• N= 560
• Mean age 76
• Transient LOC <1min, not obviously stroke, seizure or head trauma
• 2 academic/9 non-academic hospitals
• Excluded if previous syncope, on anticoagulants or pregnant
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• Ruled out N=330, 58.9%
• Scanned patients N= 230, 41.1%
• PE= 97 patients (61 main pulmonary/lobar artery or perfusion defect
>25%)
• 42.2% of scanned patients
• 17.3% of entire cohort [CI 14.2-20.5%]
• 1 in 6 patients presenting with syncope
• Data by alternate explanation:
• 45/355 (12.7%) with alternative explanation for syncope
• 52/205 (25.4%) with no alternative explanation for syncope
Prevalence of Pulmonary Embolism among Patients Hospitalized for SyncopePaolo Prandoni, et al, for the PESIT Investigators*
N Engl J Med 2016; 375:1524-1531October 20, 2016DOI: 10.1056/NEJMoa1602172
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• Clinical features in patients with PE vs those without PE
• Tachypnea (45.4% vs. 7.1%)
• Tachycardia (33% vs. 16.2%)
• Hypotension (36.1% vs. 22.9%)
• Signs/symptoms DVT (40.2% vs 4.5%)
• Active Cancer (19.6% vs. 9.9%)
• 24.7% had NONE of the above clinical features
• Didn’t include ambulatory care patients
• Within scanned patients (N= 230)
• 135: positive d-dimer only
• 3: high Wells score
• 92: high Wells score and positive d-dimer
Prevalence of Pulmonary Embolism among Patients Hospitalized for SyncopePaolo Prandoni, et al, for the PESIT Investigators*
N Engl J Med 2016; 375:1524-1531October 20, 2016DOI: 10.1056/NEJMoa1602172
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Prevalence of Pulmonary Embolism among Patients Hospitalized for SyncopePaolo Prandoni, et al, for the PESIT Investigators*
N Engl J Med 2016; 375:1524-1531October 20, 2016DOI: 10.1056/NEJMoa1602172
• Conclusions:
• Important to consider PE in new, isolated
syncope
• D-dimer use
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Back to Mr. PE:
• CT PE protocol confirmed PE
• Started on Dabigatran 150mg po BID
• AND…..
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Mr. PE at 0300 few days later:
• Acute onset Hematemesis
• Vitals: HR: 130, BP 60/40, RR 24, T 36.6
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What is your immediate management?
A) Two large bore IVs, Fluid bolus
B) Urgent call to ICU/GI
C) IV Pantoloc and maybe octreotide
D) A new dabigatran reversal agent
E) All of the above
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• Idarucizumab
• Monoclonal antibody fragment developed to reverse anticoagulant
effects of dabigatran
• Multicenter, prospective, open label study
• 5g IV Idarucizumab to reverse anticoagulation effects of dabigatran in
patients who had either:
A. Uncontrolled bleeding
B. Required urgent procedure
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• >18 years, on dabigatran, bleeding (unstable or need surgery that can not
be delayed >8hours)
• Treatment: 5g IV (two 50ml (2.5g) infusions, no more than 15 min apart)
• Blood work: Diluted thrombin time or ecarin clotting time (correlate linearly
with dabigatran concentration)
• Baseline, after first infusion, between 10-30 min after second infusion and
at 1,2,4,12 and 24 hours
• “Complete reversal” was normal blood work
• Clinical outcomes: extent of bleeding and hemodynamic stability, severity of
bleeding, peri-procedure hemostasis, thrombotic events, death at 90 days
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• N= 503 (Group A: 301, Group B: 202)
• Median age 78 years
• Group A: GI Bleeds (45.5%), ICH (32.6%), trauma (25.9%).
• Major or life threatening bleeding in 88%
• Maximum percent reversal 100% [CI 100%-100%] at 4 hrs
• Independent of age, sex, renal function or dabigatran
concentration at baseline
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• Group A: median time to hemostasis (when able to determine): 2.5 hours
• Group B: median time to procedure 1.6 hours. Surgical hemostasis: 93.4% normal, mild
5.1%, moderate 1.5%, severe 0%
• Mortality :
• Group A: 13.5 % 30 day, 18.8% 90 day
• Group B: 12.6% 30 day, 18.9% 90 day
• Comparison data with warfarin: ICH 50% 30 day mortality warfarin vs 16.3% in this
study
• Thrombotic events:
• 4.8%within 30 days
• 6.8% within 90 days
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• Safety data: 23.3% serious adverse effect but felt to
be mostly worsening of index event or co-existing
conditions. No consistent patterns identified.
Delirium, cardiac arrest, septic shock most common
• Recurrent elevation of clotting time at 12-24 hours
in 114 patients (redistribution of unbound
dabigatran from extravascular to intravascular
compartment). Bleeding in only 10 patients.
Repeat dosage can be given.
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Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.Pollack CV Jr,et al
N Engl J Med. 2017;377(5):431. Epub 2017 Jul 11.
• Patients on Dabigatran annual rates of:
• Life threatening bleeding:1.25-1.5%
• Emergency surgery:1.5%
• Cost
• Factor to consider when counselling
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Mr. PE
• Received emergent resuscitation, medications
including Idarucizumab and upper endoscopy
with local treatment of bleeding PUD
• Stabilized and recovered
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Case 3Mr.CD
• 78 year old male admitted with fever, cough, increased amount and
purulence of sputum and increasing dyspnea
• PMH: Severe COPD with frequent admissions. Past 12 months on:
amoxicillin, doxycycline, cefuroxime X2
• Temp 38.1, HR 98, BP 120/72, RR 22, 02 sat 84% room air
• WBC 11, Hgb 100, Plt 400, Cr 60, lytes within normal
• CXR: RLL pneumonia
• Levofloxacin, Prednisone, Atrovent/ventolin, DVT prophylactic
Dalteparin, Nicotine Patch
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• Any other medication or supplement you would
want to consider in the management of this patient?
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Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression AnalysisNicole T. Shen, et al. Gastroenterology 2017;152:1889–1900
• Reviews have provided evidence for the efficacy of probiotics for the prevention of CDI, but currently
not recommended on guidelines
• Systematic review of RCTs for use of probiotics and CDI in hospitalized patients receiving Abx
• Search identified 1647:19 studies met criteria, total of 6261 patients,
• Hospitalized patients, >18 years old, oral or IV antibiotics for any reason
• Probiotics: any strain or dose
• Common exclusions: pregnant, immunocompromised, ICU, artificial heart valve, pre-existing GI
disorder
• Incidence CDI
• Probiotics: 1.6% (54 of 3277)
• Controls: 3.9% (115 of 2984)
• Pooled RR of CDI in probiotic users 0.42 [CI: 0.30-0.57]
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Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression AnalysisNicole T. Shen, et al. Gastroenterology 2017;152:1889–1900
• Meta-regression analysis:
• Probiotics more effective if given closer to the first
dose of antibiotics, decrease in efficacy for every day
of delay (P<0.04)
• Probiotics given within 2 days of first antibiotic were
more effective (P = 0.02)
• 2 days or less: RR 0.32 [0.22-0.48]
• >2 days: RR 0.70 [0.40-1.23]
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Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression AnalysisNicole T. Shen, et al. Gastroenterology 2017;152:1889–1900
• Safety: no adverse effects in probiotic group
• Meta-analysis so more studies needed on specific
doses, species and formulations
• Still an “off-label” use of probiotics
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Mr. CD
• PAD 6: liquid stool, abdominal pain
• + c difficile
• Vitals: 36.7, HR 92, BP 124/68, RR 16, O2 sats 88% RA
• WBC 16, albumin 24, Cr 70, lytes within normal
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How do want to treat the c.diff?:
A. Metronidazole 500mg po TID
B. Vancomycin 125mg po QID
C. Probiotics
D. More than one answer is correct
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C.diff severity
• Severity considerations:
• Scoring system (severe = 2 points or more)
• 1 point for: Age >60, Temp >38.3 degrees, WBC>15,
Albumin <25
• 2 points for: Pseudomembranes on endoscopy or ICU
• Simplified: WBC>15, albumin <30, Cr> 1.5X normal
• Or “Clinical Judgement”
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Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of
Recurrence and Death in Patients with Clostridium difficile Infection
JAMA Intern Med. 2017;177(4):546-553. doi:10.1001/jamainternmed.2016.9045 Published online February 6, 2017.
• Comparison of recurrence and 30 day mortality in
metronidazole vs vancomycin for c.diff treatment
• Retrospective propensity-matched cohort study VA Jan
2005-Dec 2012
• Mean age 68.8 years, 95.9% males
• 2068 vancomycin treated, matched 8069 metronidazole
treated
• 5452 mild-moderate disease, 3130 severe disease
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Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of
Recurrence and Death in Patients with Clostridium difficile Infection
JAMA Intern Med. 2017;177(4):546-553. doi:10.1001/jamainternmed.2016.9045 Published online February 6, 2017.
• Recurrence:
• mild-moderate: no difference metronidazole vs vancomycin
• Severe: no difference metronidazole vs vancomycin
• 30 day mortality:
• All groups: Reduced mortality with vancomycin (adjusted RR 0.86, 95% CI 0.74-0.98)
• Mild-moderate: no difference metronidazole vs vancomycin
• Severe: Reduced mortality with vancomycin (adjusted RR 0.79, 95% CI 0.65-0.97)
• Conclusion:
• Provides ongoing support that severe CDI should be treated with vancomycin
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Mr. CD Conclusion:
• Given age, WBC count, low albumin: you treat
with vancomycin
• You know he’s alive in 30 days because he is re-
admitted again with Functional decline.
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Take home points
• Pancreatitis
• Early feeding may reduce LOS in mild-moderate pancreatitis
• Syncope
• 1 in 6 “first syncope” presentations: PE
• New Reversal agent for Dabigatran available
• C.diff:
• Probiotics given to inpatients on antibiotics for any reason may reduce risk of
developing c.diff. The earlier they are given, the more benefit. More studies
needed.
• If severe c.diff, vancomycin reduces all cause mortality better than metronidazole
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Questions?