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Inpatient Medicine: Year in Review Karen Hauer, MD UCSF August, 2006.

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Presentation on theme: "Inpatient Medicine: Year in Review Karen Hauer, MD UCSF August, 2006."— Presentation transcript:

1 Inpatient Medicine: Year in Review Karen Hauer, MD UCSF August, 2006

2 Methods Literature review March major journals Am J MedCirculation Annals Internal MedCritical Care Medicine ACP Journal ClubJAMA Archives Internal MedLancet BMJNew Engl J Medicine CMAJ

3 Selection criteria Relevance for inpatient medicine Potential to change, inform, or confirm practice Diverse topics, study types

4 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy PE Diagnosing catheter-related infection Medication discrepancies

5 Case A 75 year old man with diabetes, hypertension, hyperlipidemia, dyspepsia on PPI, and COPD is admitted with chest pain, fever, and cough. Vital signs are pulse 95, BP 145/90, resp 22, 02 sat 97% on room air. On exam JVP is 9 cm, chest clear, cardiac RRR with S4, no edema. BNP is 250. ECG shows NSR with 2 mm ST elevation in V4-6. CXR shows LLL infiltrate.

6 Question #1 You administer aspirin 325 mg. Do you give Clopidogrel? A.Yes, before percutaneous coronary intervention (PCI). B.Yes, after PCI C.Yes, if tPA is given D.No, aspirin is enough

7 Effect of Clopidogrel Pretreatment before PCI Negative consequences of platelet activation –Coronary artery thrombosis - plaque rupture –Thrombotic complications of percutaneous coronary intervention (PCI) What is the optimal timing of clopidogrel treatment in patients with ST elevation MI (STEMI)? –Initiated at time of PCI or –pretreatment

8 Effect of Clopidogrel Pretreatment before PCI the PCI Clarity Study Sabatine, N Engl J Med 2005;294: patients with recent STEMI Randomized trial –All patients received fibrinolytic, aspirin –Clopidogrel 300 mg load, then 75/day or placebo Initiated with fibrinolysis, then PCI at 2-8 days Any patient getting stent received clopidogrel after Outcome: –Primary: composite of CV death, MI, or stroke from PCI to 30 days –Secondary: MI or stroke before PCI

9 Clopidogrel Pretreatment before PCI improved outcomes OutcomeClopidogrel Pre-Rx No pre- Rx Adjusted odds ratio p CV death, MI, stroke post PCI 3.6%6.2% MI or stroke pre PCI 4.0%6.2%

10 Effect of Clopidogrel Pretreatment before PCI the PCI Clarity Study Clopidogrel pretreatment benefit –Regardless of patient characteristics –For urgent/elective PCI regardless of timing No difference in bleeding –2.0% vs. 1.9% –No increase in bleeding with clopidogrel pretreatment plus GpIIb/IIIa inhibitor Benefit of clopidogrel across a range of pretreatment durations

11 Implications of Clopidogrel Pretreatment before PCI For every 100 patients undergoing PCI –Prevent 2 MIs before PCI –Prevent 2 CV deaths, MI or stroke after PCI to 30 days Addition of clopidogrel to ASA in 45,852 patients with acute MI –93% STEMI or BBB –9% reduction in death, MI, or stroke at discharge COMMIT. Lancet 2005;366:1607

12 Question #1 You administer aspirin 325 mg. Do you give Clopidogrel? A.Yes, before percutaneous coronary intervention (PCI).

13 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

14 Case Your patient undergoes successful PCI with stent placement. You also diagnosed pneumonia based on the presentation and initial CXR and started Levofloxacin. His oxygen requirements increase over the first 2 hospital days to the point that he is intubated and admitted to the ICU.

15 Question #2 Do you initiate intensive insulin therapy in the ICU? A. No, only in surgical ICU patients. B. Yes. C. Yes, if he is likely to be in the ICU for > 3 days. D. Yes, if glucose at ICU admission is > 300 mg/dl.

16 Intensive Insulin Therapy in the ICU Van den Berghe, N Engl J Med 2001;345:1359 Benefits of strict glucose control in surgical ICU –In-hospital mortality 11% vs. 7%, (p =.01) Greatest benefit with ICU stay > 3-5 days –Reduced morbidity Septicemia: 8% vs. 4% (p =.003) Organ failure Does intensive insulin therapy improve prognosis in the medical ICU?

17 Intensive Insulin Therapy in the Medical ICU Van den Berghe, N Engl J Med 2006;354:449 Prospective, randomized, unblinded trial –Intensive: insulin with goal glucose –Conventional treatment: insulin drip with goal glucose Primary outcome: in-hospital mortality –Secondary outcomes: ICU mortality, organ failure, bacteremia or prolonged antibiotics

18 Intensive insulin therapy and in-hospital mortality p = 0.33 p = 0.009

19 Intensive insulin therapy and hypoglycemia Average glucose 150s with conventional Rx vs. 100s with intensive insulin More hypoglycemia with intensive insulin, but no adverse clinical events –Risk factors: ICU > 3 days, liver failure, dialysis Hypoglycemia was independent risk for death

20 Intensive insulin therapy in the MICU: implications Mortality benefit for patients in ICU > 3 days similar to benefit in surgical ICU But... –Cant predict length of ICU stay –Higher mortality with insulin & ICU < 3 days A reasonable approach –Aim for glucose <150 on ICU days 1-3 –Consider goal of after day 3

21 Question #2 Do you initiate intensive insulin therapy in the ICU? C. Yes, if he is likely to be in the ICU for > 3 days.

22 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

23 Case: Question #3 On hospital day 3, your patient has 4 loose stools and subsequent stool testing reveals C. difficile colitis. What risk factors might explain his developing C. difficile infection? A.Levofloxacin use B.PPI use C.Colonization with C. dif in the spore form D.Your washing your hands with an alcohol-based hand sanitizer

24 The new Clostridium difficile: what does it mean? C diff colonization –3% healthy adults –20-40% hospitalized patients –Metabolically inactive spore form until gut flora perturbed C diff virulence factors: toxins A and B –2 genes down-regulate toxin production –Binary toxin mediates potency of toxins A and B

25 Outbreaks of C diff in health care facilities Loo VG. N Engl J Med 2005;353:2442. Prospective and case control studies of C diff outbreaks at 12 Quebec hospitals C diff: 2% of all admissions –7% in patients > 90 years Mortality with C diff –25% 30-day mortality –Attributable mortality 7% 14% in patients > 90 years

26 Case control study: risk factors for C diff ExposureOdds ratio for C diff Cephalosporins3.8 Fluoroquinolones3.9 Not associated with C diff: Other antibiotics Acid blockers, enteral feeding

27 Severe diarrhea associated with virulent strain Two genetic mutations increased virulence –Binary toxin gene –Partial deletion of suppressor gene Severe diarrhea: –22/132 patients (17%) with mutations vs. 0/25 without All isolates susceptible to metronidazole, vancomycin

28 Implications:C diff may be evolving into a more severe disease 4X higher rate of C diff than in past years Prevention and control –Barrier precautions –Patient isolation –Cleaning environment with sporicidal agents –Handwashing - soap and water in addition to alcohol-based sanitizers –Antibiotic restraint

29 Gastric acid suppression and the risk of community-acquired C diff Dial. JAMA. 2005;294:2989 Case control study - United Kingdom population database –Not hospitalized in past year Factors associated with community-acquired C diff (adjusted risk) –PPI: 2.9 –H2 blocker:2.0 –Only 37% had antibiotics in prior 90 dys

30 Case: Question #3 On hospital day 3, your patient has 4 loose stools and subsequent stool testing reveals C. difficile colitis. What risk factors might explain his developing C. difficile infection? A.Levofloxacin use B.PPI use C.Colonization with C. dif in the spore form D.Your washing your hands with an alcohol-based hand sanitizer

31 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

32 Case: Question #4 In the ICU, your patient develops worsening hypoxia with stable infiltrates on chest x-ray. You suspect pulmonary embolism (PE), and you want to order a CT to evaluate. What is the best strategy to prevent contrast nephropathy? A. N-acetylcysteine B. Bicarbonate C. IV hydration, & hope he doesnt develop CHF D. Hydrate, then lasix

33 Contrast Nephropathy Major causes of renal failure in the hospital –Prerenal, Medications –Contrast Consequences of contrast nephropathy –Prolonged hospitalization –Need for hemodialysis –Morbidity and mortality - especially with cardiac disease Oops, should have thought of this before the cardiac cath

34 Risk factors for Contrast Nephropathy Patient: –Baseline renal insufficiency –DM, CHF –Anemia –Hypertension, hypotension –Age Contrast –Amount –Type

35 Contrast Nephropathy Definition –Creatinine increase by 25% or >= 0.5 mg/dl within 48 hrs of contrast Incidence – % of all patients receiving contrast Pathophysiology –Vasoconstriction -> renal ischemia –Direct toxicity

36 Preventing Contrast Nephropathy: Meta-analysis of 59 trials Pannu, JAMA 2006;295:2765 Hydration –NS superior to half NS 1 ml/kg X 6-12 hrs pre-procedure, 6-12 hrs post –D5W with 3 amps NaHCO3 better than NS before cardiac cath 3 ml/kg X 1 hr pre-procedure, 6 hrs post –Oral hydration works, but IV probably better Merten, JAMA. 2004;291:2328 Mueller, Arch Int Med. 2002;162:329

37 Preventing Contrast Nephropathy: What is the Evidence? N-acetylcysteine –Antioxidant –Dose: 600 mg BID X 2 days –Early evidence of dramatic benefit: 90% risk reduction vs. placebo (NEJM. 2000;343:180) Subsequent studies mostly favorable but less so –Summary Well-tolerated May help

38 Preventing Contrast Nephropathy: Hemofiltration Marenzi. NEJM 2003;349:1333 %

39 Preventing Contrast Nephropathy: Summary of the Evidence Yes –Identify high-risk patients –Avoid unnecessary contrast –Hydration No –Hemodialysis –Fenoldopam –Dopamine –Diuretics Maybe –Hemofiltration –Acetylcysteine –Theophylline

40 Summary Recommendations >= 2 risk factors for contrast nephropathy IV hydration before procedure Consider N-acetylcysteine Iso or low-osmolar contrast, minimize amount IV hydration after procedure

41 Case: Question #4 What is the best strategy to prevent contrast nephropathy? Risk factors for contrast nephropathy? yes C. IV hydration

42 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

43 Case: Question #4 In the ICU, your patient develops worsening hypoxia with stable infiltrates on chest x-ray. You suspect pulmonary embolism (PE), but a chest CT is negative for PE. What do you do next? A. D-dimer B. LE doppler ultrasound C. Pulmonary angiography D. Conclude that PE is ruled out

44 Diagnostic tests for PE in the hospital D-dimer: unhelpful – low specificity in hospitalized or post-op patients, or with cancer Ultrasound: specificity > sensitivity –40% with DVT may have asymptomatic PE Angiography: gold standard, invasive CT: sensitivity for central PE high –What about subsegmental PEs? Sensitivity may be as low as 29% - significance?

45 Clinical Validity of a Negative CT with suspected PE: a systematic review Quiroz. JAMA. 2005;293:2012. Meta-analysis of 15 studies using CT to rule out PE –3500 patients, 7 nations –Patient follow up 3-12 months After negative CT: –Negative likelihood ratio of clot = 0.07 –Negative predictive value: 99.1% –No benefit to additional studies prior to CT

46 Clinical Validity of a Negative CT with suspected PE? Yes! Negative predictive value of CT (99%) compares favorably to: –V/Q scan: 76-88% –Pulmonary angiography: % Visualization of peripheral pulmonary arteries –improving with better CT techniques A negative chest CT rules out PE –No further testing needed

47 Case: Question #4 In the ICU, your patient develops worsening hypoxia with stable infiltrates on chest x-ray. You suspect pulmonary embolism (PE), but a chest CT is negative for PE. What do you do next? D. Conclude that PE is ruled out

48 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

49 Case Your patient spikes a temperature to 39 degrees. On exam BP is 140/80, heart rate 100. He has no localizing findings. He has a clean internal jugular line site but you are still concerned about central line infection. How do you make this diagnosis?

50 Question #5 A.Remove the catheter, culture the tip B.Draw blood cultures peripheral and through the catheter C.Draw 2 peripheral blood cultures D.Any diagnostic approach is fine as long as I dont need to replace the central line

51 Catheter-related bloodstream infection High morbidity and mortality –12-27% mortality –Prolong hospital stay by 1 week Clinical presentation - nonspecific –Fever, +/- hypotension –No other source –Line site usually clean –Increased risk with catheter > 7 days

52 Diagnosing intravascular device- related bloodstream infection Remove the catheter –Qualitative or quantitative tip culture or.... Keep the catheter –Blood cultures through the catheter –Catheter and peripheral blood cultures Differential time to positivity > 2 hours Paired quantitative cultures: 3-5 X higher concentration of organisms from catheter

53 Meta-analysis: Methods of diagnosing intravascular device- related bloodstream infection Safdar. Ann Intern Med. 2005;142;451. Highest sensitivity –Qualitative cultures: catheter tip (90%) or through catheter (87%) –Paired quantitative blood cultures (87%) –Differential time to positivity (85%) Highest specificity –Paired quantitative blood cultures (98%) –Quantitative blood culture through catheter (90%)

54 Summary: diagnostic tests for catheter-related bloodstream infection Best test: Paired quantitative blood cultures –Differential time to positivity also accurate and more widely available Only test when catheter infection suspected –Positive predictive value of tests much higher with high clinical suspicion –Avoids overuse of antibiotics

55 Question #5 B. Draw blood cultures peripheral and through the catheter

56 Topics Acute coronary syndromes Insulin in the ICU Clostridium difficile Contrast nephropathy Pulmonary embolism Diagnosing catheter-related infection Medication discrepancies

57 Case Under your excellent care, your patient is ready to return home from the hospital. His medications on discharge are coumadin, atenolol, benazepril, atorvastatin, and omeprazole. As you handoff his care to his primary care doctor, what are the risks of a medication problem?

58 Question #6 A.None - you explained the regimen to him yourself B.He has close primary care followup so he should be fine until his clinic appointment C.You are fine because of your system to meet the JHACO Patient Safety Goal to obtain and document the patients medications on admission, and discharge D.The risk is real and a medication discrepancy would increase his risk of readmission

59 JHACO National Patient Safety Goal #8: medication reconciliation Medication reconciliation –process during a transition in care –comparing what medications the patient has been taking previously with the medications about to be provided Hospital admission and discharge: important transitions in care –Discharge medication list must be communicated to the next provider of care (not just the patient)

60 Post Hospital Medication Discrepancies Coleman. Arch Intern Med. 2005;165:1842. What are the prevalence and contributing factors associated with medication discrepancies - –prehospital -> discharge -> meds actually taken after discharge What are risk factors for medication discrepancies? Are medication discrepancies associated with readmission?

61 Post Hospital Medication Discrepancies: study population 375 Adults >= 65 years old Admitted with common conditions likely to require discharge to skilled nursing facility –CHF, COPD, CAD, DM, stroke, PVD, arrhythmia –Back conditions, hip fracture Discrepancies = what was patient told vs. what was planned

62 Categorizing Medication Discrepancies Medication Discrepancy Tool (MDT) –Meds assessed by NP hours after discharge to home Discrepancies –Systems-based: doctor or system –Patient-based: intentional or non-intentional Did they try to take it correctly?

63 Medication Discrepancies 14% of patients –38% of those had > 1 discrepancy Average # meds: 9 with discrepancy vs. 7 without (p <.001) Common offenders (50% of discrepancies) –Anticoagulants –Diuretics, ACE inhibitors –Lipid-lowering agents –PPIs

64 Causes of Medication Discrepancies Patient (51%) Nonintentional nonadherence (34%) $$ Intentional nonadherence System (49%) Bad instructions Conflicting instructions Duplication

65 Implications of Medication Discrepancies 30-day readmission rates higher with medication discrepancies (14% vs. 6%, p =.04) Transitions of care are a high risk time –Medication reconciliation in the hospital wont solve the problem –Multiple interventions needed Post discharge follow up reconciliation Systems improvements Patient education

66 Question #6 D. The risk is real and a medication discrepancy would increase his risk of readmission

67 Take Home Points Acute coronary syndromes: clopidogrel plus ASA before PCI improves outcomes Insulin in the medical ICU: tight glucose control improves survival with ICU stay > 3 days Clostridium difficile: increasingly virulent, increasingly common in the hospital and community

68 Take Home Points Contrast nephropathy: IV hydration for high risk patients PE: negative spiral CT rules out clinically important PE Diagnosing catheter-related infection: diagnose with paired catheter and peripheral quantitative cultures, or differential time to positivity Medication discrepancies: common after hospital discharge due to nonintentional non- adherence or systems problems


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