David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Preendoscopic management recommendations include the use of a transfusion threshold of 8 g/dL hemoglobin for most patients and a higher (but unspecified) threshold for patients with cardiovascular disease.
Endoscopic management recommendations include endoscopy within 24 hours of presentation for patients with acute GIB (endoscopy and endoscopic therapy should not be delayed for patients receiving anticoagulation therapy).
Patients with low-risk stigmata (clean-based ulcer) can be fed within 24 hours and discharged with a once-daily proton-pump inhibitor (PPI). Those with high-risk stigmata (active bleeding, visible vessel) should remain hospitalized and treated with a high-dose PPI intravenously for 72 hours (i.e., loading dose followed by continuous infusion). High-risk patients should then be treated with an oral PPI, twice daily, for 14 days before changing to once-daily dosing.
Secondary prophylaxis with PPIs is recommended for all patients with a history of bleeding ulcers who require continued nonsteroidal anti-inflammatory therapy (switching to cyclooxygenase-2 inhibitors should be considered), dual antiplatelet therapy (DAPT), or anticoagulation.
An editorialist notes that some questions of importance to hospitalists, such as the optimal resuscitation strategy for upper GIB patients and the optimal PPI regimen before endoscopy, remain unanswered.
Loud, bothersome snoring; apnea; and oxygen desaturation during sleep are sometimes observed in hospitalized patients. These findings should prompt consideration of OSA.
Several randomized trials have demonstrated that home sleep apnea testing (HSAT), followed by the initiation of treatment in the home, leads to outcomes similar to those of sleep laboratory testing for patients with uncomplicated OSA. HSAT measures several respiratory variables (e.g., oximetry, airflow, chest movement), but does not include electroencephalography. This technology has allowed some patients to be diagnosed and treated by their primary care providers without the need for a formal laboratory sleep study.
Untreated OSA in the perioperative setting is associated with higher rates of cardiopulmonary complications and intensive care unit transfers.
In patients with both OSA and hypertension, continuous positive airway presser (or mandibular advancement devices) can lead to reduced blood pressure, and these reductions are especially great in patients with treatment-refractory hypertension.
Wesorick DH, Chopra V. Annals for Hospitalists - 17 December 2019. Ann Intern Med. 2019;171:HO1. doi: https://doi.org/10.7326/AWHO201912170
Download citation file:
Published: Ann Intern Med. 2019;171(12):HO1.
Hospital Medicine, Pulmonary/Critical Care.
Results provided by:
Copyright © 2020 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use