Published in the December 2010 issue of Today’s Hospitalist
What’s the impact of long-term beta-blockers on COPD? What’s the best way to manage a patient with a suspected PE? And what’s the most appropriate use of vasopressors in patients with septic shock?
If you think you know the answers to these questions, you’ll be interested in the literature review presented at this fall’s management of the hospitalized patient conference at the University of California, San Francisco (UCSF). Hospitalists Bradley A. Sharpe, MD, and Michelle Mourad, MD, reviewed literature from October 2009 to September 2010 and created three case studies that address issues commonly addressed by hospitalists.
You might be surprised at what the evidence says about patients you see every day.
Case 1: A 62-year-old woman with a history of hypertension, coronary artery disease and multiple COPD exacerbations presents with shortness of breath and a productive cough consistent with another exacerbation. She has been taking 50 mg of metoprolol twice a day, which raises an obvious question:
What is the impact of long-term beta-blocker use on COPD? Is it contributing to her recurrent exacerbations, or does it have no impact on her COPD? Or is it decreasing her mortality because she has underlying coronary disease?
A study published in the May 24, 2010, Archives of Internal Medicine examined the impact of long-term beta-blockers on 2,300 patients in the Netherlands who were older than 45 and had known COPD. Just under half of the group had underlying coronary disease or risk factors for the disease.
Researchers found that over a seven-year period, the long-term use of beta-blockers decreased the rates of COPD exacerbations by 36%. They also found a 36% decrease in all-cause mortality.
“Long-term beta-blocker use led to a decrease in rates of both mortality and exacerbations,” Dr. Sharpe said. “Beta-blockers appear to not be harmful in patients with COPD and, according to this study, have a substantial benefit.”
What is the optimal dose and route of administration of corticosteroids for this patient?
A study in the June 16, 2010, Journal of the American Medical Association (JAMA) compared low-dose oral steroids (20-80 mg of prednisone per day) to high-dose IV steroids (120-800 mg of prednisone equivalents) in nearly 80,000 non-ICU patients admitted with COPD exacerbations. Researchers found that while the majority “92% “of patients received the high-dose IV steroids, they experienced very similar outcomes as those receiving the lower dose.
Length of stay and costs were statistically and significantly lower in patients receiving low-dose steroids. In addition, “the data showed a trend toward less treatment failure in the low-dose,” Dr. Sharpe said.
This study reaffirms earlier studies, which similarly found that low-dose steroids were at least as effective as high-dose steroids for mild to moderate COPD exacerbations, and that some outcomes were better.
What’s the appropriate role of antibiotics for this patient?
Another study, this one in the May 26, 2010, issue of JAMA, found that in patients hospitalized with a COPD exacerbation, treating with antibiotics in the first two days lowered mortality rates, reduced the rate of treatment failure and led to fewer readmissions. While there was a slight increase in readmissions for C. diff, the bottom line is that antibiotics showed a clear benefit. “If you’re admitting patients with a COPD exacerbation,” Dr. Sharpe said, “they should get antibiotics.”
Which antibiotic should you use?
Dr. Sharpe cited a study in the July 15, 2010, issue of Clinical Infectious Diseases that examined 170 patients sent to the ICU with a COPD exacerbation. Patients were randomized to receive either trimethoprim-sulfamethoxazole or ciprofloxacin.
Researchers found that trimethoprim-sulfamethoxazole was equivalent to cipro for all clinical outcomes. Dr. Sharpe noted that expert guidelines state that patients with COPD exacerbations should receive “first-generation antibiotics” like trimethoprim-sulfamethoxazole, amoxicillin or tetracyclines.
How much will timely PCP follow-up help this patient?
The patient is ready for discharge, and the case manager asks if you’re going to make a PCP appointment. Everyone assumes there will be a benefit to timely follow-up, but what’s the evidence?
A study published in the September 2010 Journal of Hospital Medicine asked whether timely follow-up improves outcomes of discharged patients. The small prospective study examined 65 patients at a single academic medical center, but Dr. Sharpe said the results offer some of the best evidence he’s seen supporting post-discharge planning.
Researchers looked at 30-day readmission rates for patients. Of the 49% who received PCP follow-up within four weeks of discharge, the readmission rate for the same condition was 3% compared to 21% for patients who had no PCP follow-up.
“Researchers found that patients were 10 times more likely to be readmitted for the same condition if they did not have timely follow-up,” Dr. Sharpe said. Patients with no follow-up were also seven times more likely to be either readmitted or seen in urgent care or the ED for the same condition.
Case 2: A 68-year-old man with hepatitis C cirrhosis and coronary artery disease presents with community-acquired pneumonia, but you notice that he also has low blood pressure and tachycardia. He’s complaining of pleuritic chest pain and you suspect that he has a pulmonary embolism (PE).
Is it useful to order a D-dimer for patients with suspected PE?
A study posted online by the British Medical Journal looked at the diagnostic accuracy of bedside D-dimer testing in patients with suspected venous thromboembolism. Researchers performed a meta-analysis of 23 existing studies to see how bedside assays for D-dimer compared to the older ELISA D-dimer assay.
In terms of sensitivity, which refers to the test’s ability to rule out a PE or DVT, bedside assays performed very well. But when it came to specificity “the ability of a positive test to say that someone definitively has a PE or DVT “the bedside assays came up a little short.
“A bedside quantitative assay is most useful for ruling out PE and DVT if your patient has a negative test,” Dr. Mourad said. “But this is not a good test for patients who you really think might have a PE or DVT because a positive test just doesn’t help us.” When you get a positive result, it’s really just a coin toss whether the patient has a PE or DVT.
The bottom line? “Use a bedside D-dimer assay for patients who have a low or intermediate probability of PE or DVT,” Dr. Mourad noted.
The patient has an INR of 1.7. Will this elevated INR protect him from getting a PE or DVT?
In a retrospective study of 190 patients admitted to the hospital with chronic liver disease and published in the May 2010 issue of Chest, researchers found no difference in VTE over a wide range of INRs and no difference in the incidence of PE or DVT in patients who were and weren’t on prophylaxis.
“What I took from this study is that an elevated INR in chronic liver disease is not protective against VTE in hospitalized patients,” Dr. Mourad said.
A CT scan shows that the patient does have a PE, so you start a heparin drip and admit him because he’s a high risk for bleeding. Because it was so difficult to get an IV into him, you decide to keep the IV in for a few more days. Are you putting the patient at risk for IV-associated complications by doing so?
An analysis published by the Cochrane Collaboration found that the accepted practice of routinely changing IVs every three to four days may be unnecessary. Researchers found no difference in the rates of clinically significant events like bacteremia or thrombophlebitis when nurses changed only those IVs that looked irritated or red or had stopped functioning.
The patient received a drug-eluting stent two years ago and is taking both aspirin and clopidogrel. Does he really need both medications?
A study in the April 15, 2010, New England Journal of Medicine examined patients on both therapies for 12 months after receiving a drug-eluting stent. Patients who continued to take dual antiplatelet therapy showed no benefit in terms of death from cardiac causes, stroke, stent thrombosis or need for cardiac reintervention, compared to those who continued to aspirin alone.
“This is just one study,” Dr. Mourad said, “so I would consult with a cardiologist. But these data suggest that there may not be any benefit to continuing clopidogrel for more than one year after placement of a drug-eluting stent.”
Case 3: You’re called by the ED to admit a frail, 82-year-old man with metastatic colon cancer who has presented with shortness of breath and confusion. On exam, he is hypotensive and hypoxic, and the ED physician is worried about septic shock and pneumonia. The ED physician suggests starting a pressor, which raises this question:
Which vasopressor should you start on patients with presumed septic shock?
A study in the March 4, 2010, issue of the New England Journal of Medicine looked at two initial pressors “dopamine and norepinephrine “in 1,700 patients presenting with shock. Shock was defined as a mean arterial pressure of less than 70 mm Hg despite IV fluids, in addition to evidence of hypoperfusion such as low urine output and confusion. Researchers examined outcomes like 28-day and 12-month mortality, resolution of shock, and rates of arrhythmia.
Dr. Sharpe said that for nearly every clinical outcome measured in the study, there was no difference between the two pressors. The exception was arrhythmia, where researchers found a major difference. Of patients taking norepinephrine, 12% had an arrhythmia, compared to 24% of patients taking dopamine. Most patients experienced atrial fibrillation, but a few of them had ventricular arrhythmias.
Another result: In patients with cardiogenic shock, mortality was higher among individuals treated with dopamine.
“We should be using norepinephrine as our first-line vasopressor in the treatment of all shock, and in particular in the treatment of septic shock,” Dr. Sharpe said. “This is an opportunity to work with the ED and the ICU to standardize norepinephrine as the first-line pressor.”
How important is it to prescribe the right antibiotics for septic shock patients?
A study in the Nov. 1, 2009, issue of Chest looked at patients who presented to the ED with sepsis and were started on antibiotics within 48 hours. The good news was that appropriate therapy was started in 80% of patients, with an average start time of six hours. Physicians did particularly well treating urinary tract infections, skin and soft tissue infections, and gram-negative organisms. However, they did a poorer job selecting the right therapy for patients with pneumonia, intra-abdominal infections and fungal infections.
Overall, patients who received the appropriate antibiotic therapy for sepsis were nine times more likely to survive. Patients who received appropriate antibiotics for neutropenic bacteremia, candidemia and staph aureus bacteremia were 17 times more likely to survive.
When you tell the patient’s daughter that he’s not likely to survive the hospitalization, she tells you she’s certain that he’ll pull through. How do you discuss prognosis when a surrogate decision-maker doesn’t want to hear what you have to say?
A study in the May 2010 issue of Critical Care Medicine asked what sources surrogate decision-makers use to determine a prognosis for loved ones who were critically ill.
Researchers found that only 2% of surrogates relied solely on information from the patient’s physician. The rest factored in considerations like patients’ will to live, their physical appearance, the presence of the surrogate (“I’ve been here every day”) and the patient’s faith.
The study sheds light on surrogate decision-making, Dr. Sharpe said, which may help physicians in their conversations with surrogates. When a patient or surrogate doesn’t appear to believe your prognosis, he added, it may help to ask why “and keep in mind the reasons that subjects gave researchers.
Edward Doyle is Editor & Publisher of Today’s Hospitalist.