Tuesday morning report at the VA was all about diuretics. We presented a case of a 73-year-old man with history of CHF, CKD and T2DM who presented with progressive dyspnea, bilateral lower extremity swelling, orthopnea, and abdominal distension. Physical exam showed evidence of volume overload with 3+ pitting edema, elevated JVD, and bibasilar pulmonary crackles. We considered various common triggers of heart failure exacerbation before diving into a discussion of diuretics.
Key points that we highlighted:
Decongestion with resolution of symptoms and edema is achieved through “diuresis” = loss of sodium (natriuresis) + loss of water (diuresis). That is why sodium-limited diet is crucial in treatment of fluid overload.
Loop diuretics function as “threshold” drugs that need to achieve a sufficient concentration in order to work. The natriuretic threshold is higher in patients with acute CHF than in healthy persons. That is why hospitalized patients require loop diuretic doses that are higher than stable outpatient doses.
Loop diuretics exhibit a “ceiling” effect and doses above the ceiling will not increase the amount of natriuresis. Acute CHF shifts the relation between plasma diuretic concentration and sodium excretion to the right and reduces the “ceiling.”
Patients with chronic diuretic use develop post-diuretic sodium retention and decreased efficacy with each subsequent loop diuretic dose. That is why loop diuretics are dosed multiple times daily and why patients need a net negative sodium balance each day.
Chronic loop diuretic use leads to distal tubular hypertrophy and once maximum loop diuretic effect is reached, auxiliary diuretics are sometimes used (thiazide, aldosterone antagonists, carbonic anhydrase inhibitors). We discussed specific situations you may consider using these agents.
Ethacrynic acid is the loop diuretic of choice in patients with sulfa allergy.
For further reading, check out this review from the NEJM:
Ellison DH, Felker GM. Diuretic Treatment in Heart Failure. N Engl J Med. 2017 Nov 16;377(20):1964-1975.
We are excited to announce that the applications for all our pathways are open!
This includes the following pathways:
– Global Medicine Pathway
– Hospital Medicine Pathway
– Integrative Medicine Pathway.
– Primary Care Pathway
– RACE (Residents As Clinician Educators) Track
The deadline is November 20th at 11:59pm PST. You may apply to as many of them as you would like, and we will work with you to match into one of them based on competitiveness, interest, and fit. Please note that you may do the Integrative Medicine Pathway concurrently with another pathway.
Please read the application requirements carefully (listed at the bottom of each google form) to ensure that you submit the required documents before the application deadline!
This morning one of our stellar resident, Dr. Mandy Mohindra, presented a patient who developed a fever six days into a hospitalization for volume overload. The patient reported a history of worsening chills with rigors, loss of appetite, nausea and vomiting, and fatigue. He had an infiltrated IV with right upper extremity swelling on exam. The patient’s history was significant for liver transplantation three years before (on tacrolimus), diabetes, and severe aortic stenosis. We discussed the decision to start empiric antibiotics, and the workup eventually revealed MRSA bacteremia. The most likely source was the infiltrated peripheral IV.
We were lucky to have our Infectious Disease expert extraordinaire, Dr. Annie Cowell, to lead us through the management of Staph Aureus bacteremia as we discussed the need to evaluate for potential sites of metastatic MRSA infection. A wrinkle in our patient’s case was that his blood cultures were persistently positive for MRSA. This prompted a change of antibiotics from vancomycin to ceftaroline and daptomycin and a search for endocarditis. A transthoracic echocardiogram did not reveal valvular vegetations, but a subsequent ECG revealed a new 1st degree heart block. The patient underwent a transesophageal echocardiogram which ultimately demonstrated a paravalvular abscess for which cardiothoracic surgery was consulted. Thank you to all of our resident teams for participating in the discussion. And thank you to Dr. Cowell for adding context to our patient’s clinical course!
Who: Residents can take this course prior to obtaining their own DEA – your completion will be recorded for use later.
What: AAAP Buprenorphine Half and Half Course (½ online independently and ½ “in person” via Zoom)
Where: YOUR OWN HOME via Zoom! You MUST RSVP in advance, attendance will be taken
When: September 17th, 2020; 8 am -12:30 pm (you must attend the entire time for the waiver)
Why: To be qualified to get a DEA waiver to prescribe buprenorphine products (one common brand name is Suboxone) AND to feel confident managing this growing patient population
This course is designed to equip prescribers with the information necessary to understand and prescribe buprenorphine in a safe and effective manner. It also meets the 8-hour requirement (½ in person; ½ on line) for MD’s and DO’s to apply for the DEA waiver to prescribe buprenorphine.
This training is for ½ of the 8-hour requirement. The remaining 4 hours must be done online, and you must pass a self-study exam to apply for the waiver. Contact Carla Marienfeld (firstname.lastname@example.org) if you are interested in attending.
Today our amazing future chief Dr. Averie Tigges discussed a case of a young man with SCI admitted for UTI, but used the case to discuss the greater concept of malnutrition. Averie walked us through some of the prior rationale for using pre-albumin and then discussed why it is actually not a useful bio-marker for malnutrition (its a negative acute phase reactant!) . She then discussed the different clinical scores available to assess malnutrition and highlighted the choosing wisely recommendation to utilize one of these scores over pre-albumin for assessment of malnutrition.
Today our chief of Pulmonary Critical Care division, Dr. Jess Mandel, gave us an update on our surge planning during an All-Physician Town Hall meeting for UC San Diego Health System.
UC San Diego Health System CEO, Patty Maysent, first gave an update on the resources available, testing capabilities, and provider resources. Dr. Vaishal Tolia, director of the EM department, then talked about the ED efforts for planning specifically how they improved the flow of care, incorporated telehealth, secured adequate equipment, and expanded staffing. Dr. Dan Bouland, head of Hospital Medicine, then went over the tiered plan of service expansion to plan for increased census numbers during the surge.
Dr. Jess Mandel, then went over the plan for the critical care unit. He emphasized the need to have a team based approach and went over the 9 phase plan in regards to space expansion and materials required during the surge. He also went over the number of ventilators available, and the staff expansion plan. Next, he gave us some statistics on how San Diego’s number compare to other cities and how we prepared we look in the context of the projected models.
They ended with answering all questions from the multidisciplinary audience.
Thank you all for this overview of our surge planning.
Today we were joined by Drs. Segar and Jagannath from hospital medicine (UCSD and the VA, respectively) to discuss some of the common aspects for wards, but applied to COVID-19. There is a lot of uncertainty regarding more routine aspects with COVID-19, but we tried to address several through the available literature and expert consensus.
What labs and imaging should be ordered for patients with COVID-19?
Routine labs (CBC, CMP) should be ordered, but also an RPNA and UA. Consideration can be given to PCT, LDH, CRP, troponin, IL-6, and D-dimer, but utility is unclear. Daily labs are not usually necessary and can waste PPE.
CXR is usually sufficient, but in cases of uncertainty, CT should be ordered
Which patients with COVID-19 should be admitted?
Generally speaking, anyone who would have otherwise been admitted regardless of COVID status (e.g. no PO intake, hemodynamic instability, etc.)
Often reasonable to admit to IMU (DOU) given propensity to decompensate rapidly.
Always add droplet and contact precautions to admission orders!
Who should be consulted?
UCSD: call the COVID line, VA: call ID. Otherwise, you should consult as you would for any other patient.
Be sure to notify ICU if O2 requirements are increasing, as the threshold for intubation is much lower (6L NC or more)
When can patients with COVID-19 be discharged?
Generally similar to non-COVID-19 patients (maintain adequate SpO2, stable vitals, etc.)
We have access to COVID hotels for homeless patients or those with difficult disposition options!
Remember to notify the SD Public Health Department and provide isolation recommendations.
Thanks all for the great discussion and the work you are doing!
This afternoon, we discussed two topics outlined by the Journal of Hospital Medicine’s Choosing Wisely topic series: 1. Routine TSH testing in hospitalized patients, and 2. Card Flipping on Hospital Medicine Ward Rounds.
Card Flipping on Rounds, otherwise known as “table rounding,” involves the discussion of patient care plans away from the bedside. Some of the reasons for why this is done include perceptions of efficiency, desires to shield ward teams’ discussions regarding sensitive patient subjects (malignancy or patient behaviors), or desires that certain teaching topics are more appropriate at the table rather than the bedside. However, arguments in support of bedside rounding are that bedside rounding may actually improve efficiency due to having nursing staff, ancillary services, the patient, and other members of the care team involved in the decision making conversation, thus eliminating confusing that may occur later in the day. It was also discussed that many patients actually prefer bedside rounding due to improved transparency with regard to care, as well as feelings that they were included in the decision making process. Ultimately, we discussed the need to have a balanced, thoughtful approach when choosing what rounding format is most appropriate for each clinical scenario, as well as addressing the practical time demands that often obligate a mixed use of table rounding and bedside rounding. We discussed that decisions to utilize bedside rounding for its clear benefits in patient engagement, involvement of multidisciplinary teams, and physical exam teaching were superior to that of table rounding– but that table rounding formats could be useful in times when clinical decision making is relatively straightforward (i.e. in the case of placement issues).
The second discussion we had was regarding the routine testing of TSH in hospitalized patients. While it would appear that TSH is tested for “completeness,” in reality the use of TSH in hospitalized patients very rarely leads to a diagnosis of true thyroid disease. In fact, up to 30% of hospitalized patients may have an abnormal TSH when tested during hospitalized settings, only to have true thyroid disease confirmed in subsequent outpatient testing in only 8% of those patients, yielding an incredibly high false-positive rate. We discussed the utilization of Bayes Theorem to highlight this further–as many patients who have routine testing of TSH may have a low pre-test probability of having thyroid dysfunction– using a test with a high false positive rate in that setting nearly completely ameliorates the test specificity. Nevertheless, it was noted that in some clinical scenarios where clinical findings suggestive of thyroid diseases were noted — goiter on physical exam, lethargy, or unexplained tachycardia, the likelihood ratio of underlying thyroid dysfunction was significantly elevated and the use of TSH as a confirmatory test was deemed to be warranted. In essence, developing an awareness of the statistical limitations of tests used in variable risk populations will go far to improve our understanding of diagnostic testing and their utilities in different clinical scenarios.
Intern Victoria Wu created a best practice tool to help facilitate information exchange for patients being transferred to our hospitals. Find EPIC tips for starting orders and note early to transmit vital information and a helpful list of phone numbers of common transferring hospitals in the area.
This document has been added to the CVC and MICU rotation pages!