SPEAKER_02 0:19

Hello and welcome to Inpatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. Today on the show, I'm joined by Dr. Bianca Farley as we bring out the evidence on two of hospital medicine's most dreaded complications and ask whether the practices we use to prevent rare but devastating outcomes are actually helping patients. Is slow correction of severe hyponatremia causing more harm than good? And for hospitalized medical patients, is chemical DVT prophylaxis improving the outcomes we actually care about? Let's get into it.

SPEAKER_00 0:56

Thanks for having me on. Really enjoy these two studies. I feel like one of my philosophies as a hospitalist is less is more. Yeah. And I really do enjoy this because I do feel like some of the things that as I practice is like, does this even make sense? Like, why are we doing all of this? And sometimes it's just it definitely is harmful to the patient, especially this current study in regards to like when we're adjusting sodium, how many times are we doing blood draws? And is it necessary or are we giving them three percent sodium chloride if it's really needed, or DDAVP to because we're quote unquote correcting too quickly? So it's tricky stuff. Yeah.

SPEAKER_02 1:36

And yeah, I mean, we are we're always scared of the worst possible thing that could happen. How often do you think, Dr. Farley, how often do you take care of patients who are hyponeutremic?

SPEAKER_00 1:46

I feel like all the time. Yeah. Like all the time, but it's either chronic or it's very like mild. I I will say half the time, probably more than half, let's be honest, are patients who've just been in PO waiting for procedure and then they're just volume down. But like true acute hyponeutremia, I feel like it's either us doing it from like a diuretic standpoint, or it's CHF. Um, I think when we all see like why this person has acute hyponeutremia, everyone like gets scared and they have to pull up the up-to-date and is like, do I get fluids? What do I do?

SPEAKER_03 2:24

Yeah, that that up to date is not.

SPEAKER_02 2:26

I think I've actually heard this before that the up-to-date page on hyponautremia. I don't know if it's management or workup or both is like the most visited up-to-date page, which is probably true for me. I look at it again and again all the time.

SPEAKER_00 2:38

All the time. And then you do every sometimes you do everything and it just doesn't work. And then you freak out because it's like, oh gosh, is what are I did, did it make it worse? And if I'm gonna cause more harm to the patient.

SPEAKER_02 2:53

So when you take care of, and I know this is everyone probably at different institutions say to use different levels of cares to take care of these patients, but we've all taken care of them before. When you have that patient that comes to your service or you heard about from the ED that has a sodium of 116, like what are you, what are you most worried about? What pops into your mind? What makes you scared?

SPEAKER_00 3:17

The big thing is that's definitely severe when we classify of that hyponeutremia and is is this patient a tumdon? Are they having seizures? Are they actually having like acute symptoms due to acute hyponeutremia? I think the first question when we tell our residents, is this acute or chronic? So, you know, we're chart reviewing, is this patient stable? But at our institution, anything less than 120, that does not come to the fore. Right. That goes straight to the unit. So you and I are probably not going to acutely manage those patients, but I will say, like different institutions, even like community hospitals, their ICU is definitely open and it's up to the hospitalist with, like, say, a critical care consult or even our nifty nephrologist to help manage these patients.

SPEAKER_02 4:04

Did you uh do you have a mnemonic for the complications with overcorrecting sodium disorders? I feel like one in my head I remember from first aid that I I think of all the time whenever I'm taking care of.

SPEAKER_00 4:16

Oh, I think of is is the demyelinating syndrome. Yeah, totally.

SPEAKER_02 4:20

I mean, like that's yeah, like the in first aid there was high to low, the brain will blow, low to high, the ponds will die. And so we all we all have this like it's this is like from from being a med student, it's beat into our minds to be afraid of osmotic delimelination syndrome. Like that's that's the terrifying thing. And actually, we did an episode uh a few episodes back uh with Dr. Kevin Baker and talked about correcting hypernatremia and how there's no evidence of clinically significant cerebral edema with the brain blowing, and also there's data that correcting faster generally has better outcomes, uh, foreshadowing here to our article. But like at the time, I was like, this is super important. Like, don't throw the mnemonic out because like osmotic demyelination syndrome is a real thing. You don't want to get people locked in. It's a totally different boat, and it is a different boat, but it it is seeming that it's it's also a little more complex than than I realized at that time. Yeah, and this article has been really interesting to that effect. Yeah. You want to tell us more about the article?

SPEAKER_00 5:33

Yeah, so this gives you the whole like title sodium correction rates and associate outcomes among patients with severe hyponeutremia, keyword severe, so less than 120. Um, so this is a retrospective cohort study. I think it was like Kaiser in California, like they used a database with Kaiser, but from all of that, um, the nth was it's a pretty significant number, like almost 4,000 patients. Yeah. Um, and so the the bottom line, the question that this article that they were from the study was is correcting severe hyponeutremia versus slow, which is less than eight micro or mil equivalents for medium, which I believe it was like eight to 10, 8 to 12. Yep, eight, and then faster greater than 12, was there going to be rates of associate better 90-day outcomes compared to slow correction between medium or faster 24 hour? And essentially, this is like again, they retrospective cohorted study, they went back from I think 2008 to 2024. So and what they did found the the the big outcome, the primary outcome is that slow rate actually there was a higher outcome of like death for these patients versus the medium to fast correction. And it didn't really change like the amount of time they're in the hospital, though, which was also interesting. I think it was like one day, but the overall mortality outcome was very interesting.

SPEAKER_02 7:11

Yeah. I mean, yeah, I think I think this is a really cool study because of yeah, the outcome they looked at 90 days, a pretty long follow-up time, which yeah, benefit of this health system. But the fact that they did the composite outcome of death and the neurologic complications, like this is the stuff we care about. How our patients actually do, like, what's their morbidity? Are what's their mortality? Are they dying? Yeah. And it's the thing we're so specifically so scared about that's driving our correction rate of the neurologic outcomes. And the fact that they looked at both of those for 90 days and found that the sl, like if you correct at the rate that we all think you're supposed to to prevent these neurologic outcomes and prevent this terrible things like death, they're actually doing worse. It's really it's it's impressive, it's really compelling. And I was surprised.

SPEAKER_00 8:04

Yeah, I I definitely was too, for sure.

SPEAKER_02 8:08

Um like as as we often have the the case with retrospective trials, I always have to wonder, like, what what was it about because they weren't randomized, this wasn't prospective. Like, what was it about the patients that we corrected much more quickly that they ended up correcting more quickly? Was it something about their physiology made it so they they just sort of auto-corrected or on their own corrected more quickly? Or was it something about the was it something to do with the provider's impression of the patient that they thought they had that wiggle room to correct more quickly, which obviously could skew results. Yeah.

SPEAKER_00 8:47

And that would be kind of uh interesting because I one of the things that they obviously included when we're talking about correcting hyponeutremia, particularly the patient populations that are malnourished, they have cirrhosis, those are the patients that they said even those patients, you definitely have to be very careful how quickly you correct them. So I out of those patients, I I am interested because I don't, and you can correct me if I'm wrong, but I don't remember seeing anything about how do those patients do. Were those the patients that had like the 13% that ended up with their pawns dying?

SPEAKER_02 9:23

That's a good point. I don't think I saw off the top of my head, I don't remember seeing a subgroup analysis based on comorbidity.

SPEAKER_00 9:31

Yeah.

SPEAKER_02 9:31

They included all those patients. Like I think I like uh they had 14% had alcohol use disorder, 18% had liver disease, 24% had CHF, the median age was 74. So these were, I mean, as the people are who tend to get hyponatremia, people who are older, frail, and have these comorbidities. So they were they were in the study, but yeah, I agree with you. The subgroup analysis could be really informative. And I think it alludes to one of my big takeaways from this, and from all of this, is one is often less is more. Then two is treat the patient in front of you. Uh like you're saying, if your patient who you're getting called about, who you're seeing who has a sodium one 116 is actively having neurologic complications, then you got to fix them quickly for sure.

SPEAKER_00 10:22

Yeah.

SPEAKER_02 10:23

And or you think their risk is low, then you should be fixing them quickly. And so you there's there's more work to be done before we just take this carte blanche and say, okay, it's a new world order when it comes to correcting hyponatremia, throw your mnemonic out the window. That is that needs to be like you're saying, what's the patient population we're really worried about? How do we how what do we need to do to be improve people's sodiums quicker so we improve their outcomes pretty significantly, but also do that in the right patient so that we're not we don't end up going the pendulum swinging the other way and going too far. Do you what's your uh when you manage a patient with hyponatrime and you're trying to correct them, do you have like a mental number that is your your go-to goal of of correction per day?

SPEAKER_00 11:12

I it's funny that you say that because to personally for me, I correct between eight to ten. So I probably actually in the moderate corrector. I don't I definitely wouldn't go greater than 10 just because that that makes me feel uncomfortable. Of course. But 10 within 24 hours, I would be like my max. I I am an average eight to ten.

SPEAKER_02 11:32

And that that was the the the guidelines was less than 10 and but less than eight if the patient was high risk. Yes. So yeah, but a lot of us, I mean, I mean, I'm kind, but I I'm with you. I'm I'm less than 10, or maybe, maybe sometimes even less than eight. I have like a very low threshold to be like this person's high risk. But the thing is that I do, and I think a lot of us do, is it's like it's not exactly that my goal is eight. My goal is, if I'm worried, is less than eight. And so I am fleeing from that number. And when I'm trying to do less than eight, I'm wanting to err on the side of caution. And a lot of times I'm ending up doing five or whatever and going really, really slow. Yeah. Which that's another thing that's kind of changes for me. That I don't think I can in a vacuum be like, I don't care about osmotic demyelination syndrome. I'm gonna have a goal of greater than 12 in everybody now. But my goal is not gonna be just less than 10. It's maybe gonna be more like eight to 10. And I'm gonna be prioritizing, not going too slow either.

SPEAKER_00 12:46

Yeah. And then like we said, I think it's, you know, what your patient, what your patient's doing. If it's a younger patient, I'm not as worried. I mean, their body, I feel like you could potentially those those patient populations, we could potentially correct them probably within the 12 range. I mean, I can't tell you how many uh young patients I have who are drinking too much water and over-exercising, and then they end up in the ICU because their sodium's 109.

SPEAKER_02 13:15

Yeah, and that's another we have, we all have the again, it's being so terrified of osmotic demyelination syndrome that we have the rule of thumb of if we can't prove it's acute, if we don't have that number within X amount of time beforehand that's normal and we saw it go down, we assume it's chronic. But to your point, why are you assuming that healthy patient who's super dehydrated or something like that's going on is chronic? You we we know, like you and I, we admit this, people, we know it's not chronic, but we treat them with that slow correction because we assume they're chronic. And really, the only time we feel comfortable aggressively correcting someone because it's acute hyponatremia is if they if it happened in the hospital, we did it and we saw it happen, then we can say, okay, we can just undo this, no big deal.

SPEAKER_00 14:08

Yeah.

SPEAKER_02 14:09

But we probably that's another thing we probably need to sort of mentally shift is like just don't don't assume everybody's chronic. You're you know, your cirrhotic, your little old lady, which the serrhotics are kind of their whole end, yeah. But your your little old lady who's clearly dehydrated, you know, this patient, 74 something, like, yeah, she's probably chronic. She's probably been sitting there a while, but there's a lot of the population that clearly isn't that we certainly can be more aggressive with. And that's probably part of why we're seeing they do more poorly because their brain is not used to living sodium of 116. Right. And we're just we're causing the opposite problem.

SPEAKER_00 14:46

We are causing more neurologic problems because they're just sitting in this like terribly hypotonic state that their brain just does not have the ability to come back from. Yeah. And especially the demented patients.

SPEAKER_02 15:01

Yeah, certainly. Yeah. Yeah, certainly. That's that's actually a fantastic point. And part of why we're seeing mortality be worse and all of that is these people don't this patient population that gets this usually doesn't have a lot of reserve. So yeah, if they get poor outcomes or something that puts them down a couple rungs, they may not be coming back from it. Have you ever had patients with osmotic demyelination syndrome? Never. Yeah. I've definitely never seen it in anyone who's had their sodium corrected. I actually recently had a patient who they had called it on an MRI from a previous hospitalization. And I was like, I'm not, I'm not sure I've ever seen a patient that that was even called, like personally taking care of a patient that like had a history of it or anything. And he didn't, he was a patient with alcohol use disorder and other poly substance use, and he wasn't he clearly wasn't neurologically perfect, but he certainly wasn't locked in. That's what I was saying, he was well locked in, yeah. And so, like, I reading this study, I like because I was shocked because I was so we we just are trained to be so afraid of that, and the guidelines back it up because the guidelines are so afraid of that. I was like, where did this fear come from? How common is it actually? And I looked up a little bit of stuff about osmotic delineation syndrome, and it's obviously like in the general pop population, the incidence is very low, 0.6 incidences per million person years. So super uncommon. But there was actually a really big study from a couple of years ago that looked at almost 23,000 patients that were hospitalized with hyponatremia. And even in that population, only 0.05% of them had osmotic demyelination syndrome. So, and of that, only 42% had a documented fast correction of sodium. Over half of them. So hyponatrimic patients, hardly any of them, 12 of 23,000 of them got osmotic demyelination syndrome. And then of those, less than half of them did we even have a documented overcorrection. And they used a threshold of more than eight. So, like the very conservative threshold, which really makes it look like this from these numbers, it's it's hardly related to the correction at all. And it's so infrequent. And I think that's what we're doing here, and I kind of mentioned this at the top, and we've talked about this, is like there's this terrible specter of something terrifying that we're trained from an early age in our doctorhood training uh to be terrified of it. And it's horrifying just on a visceral level, the idea of being locked in from osmotic demyelination syndrome, the idea that you would do that to a patient is terrifying. And it seems from this data that our fear of that has driven us as the medical community and us from a guideline perspective and our individual practices to be overly cautious to the point that we're actually causing harm because we're not doing what they need to do because we're scared about one specific problem and ignoring the multitudes of others that happen if we don't do what we need to do and fix the patient's sodium.

SPEAKER_00 18:28

And I think the fear, you know, I think for all the fear of like, did we mismanage that patient? Did we cause this? Am I gonna get sued? I think that's the keeps us that keeps that fear. I mean, I I there's always you always need a healthy fear of medicine. Like you can't have a doctor that's too cocky because if that's when things start to become harmful. But I think it's good that we're questioning this because it's it to me just is it sounds like we're actually doing more harm than good. Um, again, disservice to the patients, like yeah, it didn't change how long they're in the hospital. But if if we're doing something that's causing poor outcomes compared to something that's like not even one percent, then definitely we need to take a look and do we need to be adjusting current guidelines?

SPEAKER_02 19:22

Totally. And in this study that the incidence of osmotic demyelination syndrome was really low, it was less than one percent in all three groups. And no, for that specifically, there was there was no significant difference. It was, I think, seven in the low group, six in the medium group, and five in the fast group greater than twelve, did they document some demyelinating disease, which is and looking at this, a lot of it is you know, we see a neurologic change, we get an MRI and we see something there. It's not necessarily the locked-in presentation that we all fear. So, what do you think? Does is this trial, is it gonna change your practice going forward? And if so, how?

SPEAKER_00 20:00

I wouldn't say change because I feel like if I was already in that medium correction, I probably won't be as as worried. I again, I to me, I still don't feel comforta I wouldn't feel comfortable making that change, 24-hour change of of 20 mil equivalents, but it makes me feel more comfortable that I still have a little leeway. Um, and then I probably especially if I'm giving sign out, like, you know, don't feel, you know, just giving them a little, like maybe I don't have to give them a full liter of D5W if they're correcting too quickly. Maybe I just need to give them 500 or just let's see what they do. Right. Um, and then maybe I don't have to keep like I don't have to check Q4 hour sodiums because again, that's uncomfortable for patients. But I think we have we have some wiggle room and that makes me feel a little bit more comfortable that I have a little bit more wiggle room on how I'm going to treat my these patients with hyponeatremia. It also makes me feel that that maybe I wasn't like being outrageous of of making the median correction because people are like, You really do the medium? I was like, eh, I mean some of that I can't tell you how then how the nephrologist will page me and says, You need to give them demo desmopressin, they're already correcting by 10. I'm like, it's it's okay.

SPEAKER_02 21:15

Like the big question is, okay, how how do we move forward? Because I think there is change that needs to be made in practice, but it's hard to uh to to stand out on that, on that plank on that island by yourself and be the only one who's saying, like, hey, this is okay. I think one of the things that's gonna change for me is I'll think of things with my correction almost as more thinking about the floor for the rate of correction instead of the ceiling. My my checkout is historically banned. Like, hey, if they correct over this much, I'll calculate the sodium. And if it ends up that it's going to be more than eight for the day or 10 for the day, I'll be like, if it's higher than this, then give them some free water of whatever way to bring it back down. And I I think maybe my correction, my checkout should probably instead be like, hey, if it's less than this, then we're not moving fast enough and we need to be moving faster. It needs to at least be that as well. Yeah. Or maybe that instead, except for like you're saying, to the most extreme degree of overcorrection. I think if someone is naturally correction correcting with whatever resuscitative measure we're giving them, then whether it's not giving them the free water, if it's SIADH or we're giving them some volume, then like let their body handle it. And if that handling it is 11 in a day, it's 12 in a day, is in this case more than 12 in a day, that's probably to their benefit.

SPEAKER_00 22:41

And I will also add, especially the patients that are asymptomatic with severe hypotremia, like if they're if they're completely asymptomatic, like let their body, I feel like we should give their body a chance to kind of correct a little bit faster. Yeah. Because I mean they've already overcome like they over-decrease their sodium to like what it shouldn't be physiologically. So if maybe us just not having to give, you know, so much fluid, let their body do what it needs to do, especially if they're young. I feel like young people have so much reserve.

SPEAKER_02 23:17

I'll touch on another article related to this just because I do think the it I thought it was interesting. I don't think I'll feature it fully on an episode, and I think it it plays into this a little bit. Because the there is the point that this again is the severe hyponatremia. A lot of these were probably acute, some of them might have been chronic, but that like 130 to 120 chronic range, we don't necessarily need to be treating that same way. And I think this is a similar time where less is more, and that there was this trial, there was the HIT trial. This was in, I believe, the New England Journal of Medicine. And this was a prospective study where essentially what they did, they had 2,000 patients and they had this really aggressive correction program to get their sodium up above 130 for everybody. And these people who were deemed likely chronic, moderate hyponatremia, some of them were less than 120, but most of them were in that 130 to 120 range. And what they found was yes, they corrected their sodium up to 130, more likely. But what they also found was they didn't have any of the outcomes we really care about, other than just a number that were better. So the mortality wasn't better, length of stay, and that kind of stuff wasn't better. And so I think that goes just is another nuance to this, and why it's more about treating the patient than it is treating the number, is that for your severe hyponatremia, that's dangerous for a patient. We should probably be treat treating those more aggressively and correcting that quicker. For your moderate chronic hyponatremia, their brain lives there, and if they're asymptomatic, right? Yeah, their body's used to it. And not only do you that's the patient you're really like you're not gonna help them out by just perseverating over the number and getting the better. And we all have that patient that we say, like that, you know, the ED's calling us, and they're like, oh, they need to come in because their sodium's, you know, 127, 126, 128, whatever. And we're like, it's always that. They're like, but it wasn't that when we discharged. It's like, yeah, that's because we did whatever. We were we wouldn't let them drink for three days, and then they went home and they drank like normal and they were back to normal. And hey, they're not here for anything related to the sodium, they don't need to come in. And so we can fix a number and make it shiny, but that's not necessarily going to fix an outcome. And I think that's particularly uh for these moderate hyponatribia patients. Dr. Farley, what do you think in the hospitalized patient, what do you think is the number one most frequent medicine you write for your patients?

SPEAKER_00 26:04

DBT prophylaxis.

SPEAKER_02 26:06

You think so?

SPEAKER_00 26:06

Yeah. I think so too. And and if we even if you try to avoid it, the pharmacist will message you and say, Hey, do you think this patient needs DBT prophylaxis? Yeah. Tell me I'm wrong.

SPEAKER_02 26:17

No, yeah, um, 100%. It's I I agree. I think the number one, and I haven't looked at the numbers for this, but it was the question that popped in my head and was I think sub Q low molecular weight hephtharin, subclue anoxyparin is the number one medicine I order for patients by number of orders. And you're right, it's baked into our order sets. Yes, it's baked into our institutional protocols, it's obviously baked into pharmacy checklists. It's also another thing that, like we talked about, we are we have the fear of God putting us about missing it. And so everyone's alarm bells are going off if you if your patient doesn't have it. But I agree. I think it's the number one thing we order. How often have you do you think you've seen a patient get a you think that got a thrombus that while they were in the hospital or associated with a hospitalization?

SPEAKER_00 27:14

I personally never had it, but I've heard it. I mean I would probably in the past year probably heard maybe about one. Um, since I've been in attending, maybe five.

SPEAKER_03 27:24

Yeah.

SPEAKER_00 27:25

Maybe five. And those are because it's such quote unquote rare thing for us to see that they're always presented on these MMs.

SPEAKER_02 27:35

Yep. But it's the kind of thing that similarly to osmotic demyelination syndrome, the preventable hospital-associated clot is a thing that we're really terrified about. And because of that, there is this deeply ensconced culture protocols practice pattern within, I think, every hospital of what we're fleeing from that outcome. And so I was excited to see a study that looked at actually a big study that big numbers that looked at, hey, is this actually helping patients or not? Right. And so this was a an article that came out in the uh JAMA. It was actually this is this, this just came out last month. Um, and it was about pharmacological thrompoprophylaxis and medical patients. Marty at all the authors, and they specifically, it was a big systematic review. There's actually been a decent amount of randomized controlled trials, prospective trials, and all of this of is it working? And a lot of them have been pretty equivocal and not clear. So this used looked at a bunch of studies. There were 22 randomized controlled trials included in the meta-analysis, which ended up covering 43,000 patients, almost 44,000 patients. And what they specifically were looking at was uh if they had 90-day follow-up, a 90-day outcome of symptomatic venous thromboembolism, and then they did a uh secondary outcome of clinically clinically relevant phenotheromboembolism. And that's important because there have been some studies that in favor of doing the DPT prophylaxis that we all do reflexively, that were they went and hunted for the clot. Right. So they they were throwing down the ultrasounds, and I hadn't looked in those studies. I don't know if they did before and after, but I think we've all who've practiced enough know that if you go hunting for, if you go ordering CTA chests and lower extremely Dopplers on all of your patients, you're gonna find a bunch of clots. That always don't necessarily matter. And so they looked at clinically significant, uh specifically, they were looking at the symptomatic. So they were looking for a reason the patient had symptoms of a TVT, or the patient had, God forbid, a fatal PE or symptomatic PE, that then they looked for, like any of our rapid response patients that were going to, and all those MMs that you've been to. And what they found was interesting. So in the patients that didn't have any treatment for DVT prophylaxis, the incidence of symptomatic clots was 1.7%. And then our best drug was the low phenoxy and oxyparin that uh you and I certainly tend to use. And but it was a drop down to about 1.2%, but a relative risk of 0.68. And that was statistically significant. A DOAC on ones they looked at with a DOAC also had a reduction, but it wasn't statistically significant. I'm a little bit have a hunch that some of that was because it just wasn't powered to be such, because not a lot of people are using DOACs as their DVT prophylaxis. And then for straight up heparin, unfractionated heparin, also had a reduction in clots, but it also wasn't statistically significant. And so that was impressive to me because certainly the numbers are there for heparin. We order a lot of heparin for DVT prophylaxis. Certainly our go-to is Lovinox, but we order a lot of heparin for it. And they're saying that in this study, for their primary outcome of the symptomatic clot, there was no statistically significant uh reduction in clots. And then the other interesting thing, and the clinically relevant clots were really pretty pretty similar a lot across the board. Things got a little bit more statistically significant. But then what I was also really interested in is what about the harm? Because are we doing this and it's maybe a little bit helpful, maybe not helpful, maybe it's one of those things we do for no reason, or is it one of those things that we're doing for little to no reason because of a bad outcome and it's actually causing harm? So they did look at major bleeding. And and folks that didn't get any DVT prophylaxis, 0.5% of them had a major bleed, but there was no statistically significant increase in major bleeding with LOVINOx, but with Heparin and the DOAC, that both of them had a statistically significant increase in major bleeding. Um and so the estimated number needed to treat that they gave us for giving your patient LOVINOx to prevent one symptomatic clot was 200. So their number needed to treat for DVT prophylaxis was 200. So what do you think? How how is this? Were you convinced? Is this how is this going to change the way you feel about the number one most common medicine? We think, at least off the top of our heads, that we order.

SPEAKER_00 32:50

I think in regards to I think the key word is obviously acute acutely ill patients. Right. I also think about how many acutely ill patients that come in that are already bedbound, they're definitely not on DBT prophylaxis.

SPEAKER_03 33:04

Right.

SPEAKER_00 33:05

So I don't know. I would probably say I would for those patients who are bedbound, probably already has a chronic DBT, but like they're if they're not doing that at home and they're bedbound, why are we doing it here? And I guess if you really feel worried about not giving them something, then I would be compelled to obviously do Lovinox just given those numbers. Like I mean, you know it will help prevent DBTs, the the risk of bleeding is definitely less. But then you also have the questions about what about those patients that have CKD or BSRD? Should like the AKI. Yeah, and the only thing we can give, because pharmacy is ringing news, like we can't do Lovinox, you can't even renally dose, so you have to give them heparin.

SPEAKER_02 33:47

Yeah, what percentage of our patients we're admitting have an AKI or or renal disease that makes us uncomfortable to give Lovanox?

SPEAKER_00 33:54

A lot. That's a lot greater than 50%. And so now it sits there, it's like if we already know heparin's not gonna change for them to get a clinically significant venotrauma embolism, and then the bleeding risk is definitely there, then why why should we do it? Should we if we're gonna do it, then shouldn't we wait to see if their kidneys are gonna get better if they have an AKI and then do it if they're that risky? But now it makes me question is heparin even worth doing?

SPEAKER_02 34:24

Yeah. I I had the same, I had the same thought. And I was gonna ask you going forward, you get that patient, and and pharmacy, you know, if you get a good pharmacist, they'll tell you, like, as long as we know consistently what their creatinine clearance will be, what their GFR is, then we could dose the the lobinox appropriately. But that patient that we think it might be dynamic, it's getting worse, it's getting better, we don't, we can't, we can't do it. And so for that patient, like our like based on this, I'm inclined to let never write heppern for these patients again. Yeah. Just to hold off and and know that the incidence of these these symptomatic, these c these ones that actually are making a difference in an outcome for a patient that we actually care about, which is them having some sign or symptom, rather than we just we found it because we hunted for it. Yeah, it doesn't really make a difference and it makes them more likely to bleed.

SPEAKER_00 35:19

Yeah. I agree.

SPEAKER_02 35:22

So I yeah, I I'm with you. I think it's a the number needed to treat of 200, you know, it's a good ways into the triple digits number needed to treat sounds like a big number, but how long do you think it takes you to get to 200 patients you're caring for that you're considering writing DVT prophylaxis for?

SPEAKER_00 35:48

I mean, I guess it's the A is depending on the season in the hospital, let's be honest. But I would probably say a month. Yeah if you're one a week on as a typical hospitalist.

SPEAKER_02 35:58

I agree. You we probably touch 200 patients in Yang.

SPEAKER_01 36:02

Yeah.

SPEAKER_02 36:07

Like it makes a difference. And so I am, I I was I was heartened by that in a way, even though we're we're working on the margins here, that it is making a difference that Lovinox is reducing the rate of clots and is worth doing. But if the other takeaway I kind of have from this is if a patient has any reason not to, whether it's the renal dysfunction, or I'm a little more worried than usual about bleeding, or the patient is like, I hate these Lovinoff shocks. Like we're we're working on the margins here. Yeah, it's probably okay to just be like, okay, we'll stop it. It's just not the the big deal that we think it is.

SPEAKER_00 36:42

So, I mean, when I talk about my practic change in practice, I'm definitely will be doing Lovinox for now on. But definitely, definitely thinking twice like again, my bedbound patients, they weren't doing this at home. Do we really need to do it? Can we just monitor risk versus benefits? Or is this a conversation? Do we need to be having our patients who who doesn't qualify for sub Q Lovinox and will will qualify for heparin? But now that we have the data, like it may not be helpful and actually provides more harm. Is this a risk versus benefit with the patient? Like, these are the like data showing this, but you know, you are high risk. What are your thoughts on this?

SPEAKER_02 37:23

Yeah, agreed. I think a nuance here. Don't don't apply this to your patients that are getting surgeries, that are having procedures. That's a totally different bucket. But for the general medical patient, the DVT prophylaxis, Lovinox great, but we're working on the margins here. Any other thoughts on this? On this side?

SPEAKER_00 37:42

No, I think kind of going back to the philosophy, which I feel like everyone should have is less is sometimes more.

SPEAKER_02 37:52

So today we looked at two standard hospital medicine practices, and we asked by doing these things to avoid a very specific harm, are we ultimately benefiting patients or are we causing unintended consequences? And when it comes to correcting severe hyponatremia, sodium less than 1 to 20, the retrospective data indicates that current practices and guidelines are too constrictive for a slow correction of less than eight or even less than 10. We may be causing harm to patients. And for my practice going forward, I'm going to target to be more aggressive, have a floor of at least eight, and not be paralyzed running away from that. But for the chronic hyponatrimia patient, sodium in the 120s comes in asymptomatic. We probably don't need to perseverate over that number. We're probably not significantly changing outcomes with that patient. There's a nuance there, different. Treat the patient treat the patient, don't necessarily just treat the number. But when it comes to DVT prophylaxis, for appropriate hospitalized medical patients, low-vinox is worth doing. It was shown that if you treat 200 medical patients with low-vinox, that's what it's going to take to prevent one symptomatic clot, which for us is nothing to shrug out. But when it comes to a DOAC, which I wasn't using anyway, for clots or heparin for clots, I'm going to think twice, three times before I do heparin for clots and really think, okay, this patient really needs it. I think they're high risk. Again, treating the patient in front of me. If I think they really need anticoagulation, doing it. But if I think they can get away without it, particularly if they have a contraindication to love vinox, I'll be avoiding it. Well, Dr. Farley, thank you so much for joining.

SPEAKER_00 39:48

Of course, Dr. Turner, I appreciate it.

SPEAKER_02 39:50

And to the listeners, if you found this useful, share it with your colleagues, trainees, or anyone involved in inpatient care. And finally, you can also get key takeaway show notes, article links, and new episode alerts sent straight to your inbox. Uh have a new email list going. So if you want to get on that, uh there's a link in the show notes, or you can sign up at subscribe.com. And thank you so much for listening. This has been Inpatient Update.