A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.
“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”
The Rapid Fire track proved popular with attendees; each topic drew a packed house.
“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”
Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:
“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.
“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.
“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.
“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:
- Prolonged chest pain and normal troponin;
- Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
- Normal troponin and atypical symptoms in the same patient type.
“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:
- 1 mg of protamine for every 100 units of heparin;
- No greater than 50 mg of protamine at one time; and
- Infusion should not exceed 5 mg/min.
“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.
“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”
“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:
- Brain and neurovascular imaging;
- Blood glucose and serum electrolytes;
- Complete blood count with platelets;
- Prothrombin time/partial thromboplastin/international normalized ratio;
- A 12-lead EKG and Holter monitoring;
- Transthoracic echocardiogram/ transesophageal echcardiogram; and
- Supplemental oxygen fever reduction and lipids.
“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.
“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.