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.
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.