#NephMadness 2019: Sata’s Selection for the Hospitalist Region

Posted on March 28, 2019 by AJKDblog in NephMadness // 0 Comments

Suchita Shah Sata @SuchitaSata

Dr. Sata is an academic hospitalist at Duke University Hospital and Assistant Professor of Medicine at Duke University. Her focus is on high-value care education and she is active in quality improvement work to reduce waste. She is also the President of the NC Triangle Chapter of the Society of Hospital Medicine.

Competitors for the Hospitalist Region

Perioperative ACE Inhibitors vs PRN Hydralazine

Lactated Ringer’s vs Normal Saline

I’m calling it now: the Hospitalist Region is going to produce the overall winner for NephMadness 2019. It will be a hard-fought battle of tough and common clinical decisions: blood pressure management (perioperative control and asymptomatic hypertension) and IV fluid choices (abnormal saline and the surgeons’ solution). As a champion for high-value care, I’m rooting for PRN hydralazine to go all the way (and then go the way of the dinosaurs). First, let’s meet the competition:

Lactated Ringer’s vs Normal Saline

I first had my approach to IV fluids challenged during a MICU rotation during residency, when my attending mentioned the recent publication by Yunos et al of an intriguing trial out of Australia. The possibility that we could decrease the need for renal replacement therapy was practice-changing for me, and catnip for a cost-conscious clinician. I even started paying attention to the chloride values on all those BMPs, and I became an LR lover. For years I’ve been teaching my learners to reach for Ringer’s. The publications of SALT-ED and SMART have been huge in supporting this clinical practice.

I’m particularly struck by how, in these studies, we are seeing differences in kidney-related events even with a relatively small volume of fluid received. This conversation is critical for hospitalists, in our own practice and also as we educate our trainees. A bag of fluids may not be as benign as we once thought. I’m asking myself, “How aggressively will I preach about LR over NS the next time I am on service?” With these two big studies, as well as the other ongoing RCTs, the debate is shifting away from personal preference and towards avoiding patient harm and adverse outcomes. And, of course, the downstream costs of care that accumulate from iatrogenesis.

Admittedly, the best resuscitation fluid is the fluid you have available. Many of our hospital floors don’t stock much LR but do stock plenty of NS. Maybe that’s a local practice that we will soon change (and this would be in a hospitalist’s wheelhouse of quality improvement work). But for now, if my patient is hypotensive and needs a fluid bolus, I’ll use whatever the team can grab fastest…as I enter the order for Lactated Ringer’s.

Perioperative ACE Inhibitors vs PRN Hydralazine

Consulting on surgical patients for perioperative management is a highlight of my work as a Hospitalist, and an opportunity to make a big impact on a patient’s care. Our guidance can significantly influence a patient’s postoperative course and recovery. So, we look to guidelines and expert society recommendations. If you ask me about cardiac risk stratification for a patient in pre-op, I could rattle off an algorithm and cite some high-quality evidence without pause. But perioperative medicine is not just about the heart, as kidney function and blood pressure control are also priorities.

Guidelines around what to do with renal-protective antihypertensive medications have not been consistent. The US Guideline recommendations are different from the EU Guidelines which are different from the Canadian Guidelines. Even a Cochrane analysis can’t definitively guide us on what to do.

For most of the patients I see (sick, hospitalized, with multiple medical comorbidities), I end up advising holding the ACEi or ARB pre-operatively (day 0 or -1) and restarting based on how the patient does post-op (and usually by day 2). But that’s just me; I would love to know if I’m right or wrong. We need more data to guide our practice here.

As perioperative ACEi/ARB is still such a clinical gray area, I’m expecting this tournament matchup to be an easy win for PRN hydralazine. It is a rite of passage: being paged about an elevated blood pressure, being compelled to do something about it, and then reaching for the IV hydralazine. It happens to interns of all specialties and hospitalists as well…sometimes multiple times a day. We shouldn’t expect a different response when we label the phenomenon as an “urgency.” Don’t just do something, stand there! – that’s difficult to do unless we educate and change the whole culture of a hospital, including nurses, ordering providers, and the EMR’s nudges.

PRN hydralazine poses a potential harm to patients. Aggressive treatment of asymptomatic hypertension is low-value care. This tournament entry has the potential to be a huge practice changer for hospitalists and inpatient medicine everywhere. It also has the potential to be the overall winner for this region, and it’s my prediction for the tournament champion, too.

– Guest Post written by Suchita Shah Sata @SuchitaSata

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