"Interesting" Practices

[turkeyjerky]

Hey all, EM doc here and recently I've recently seen a few practices that I find a little atypical:

1) PRN anti-hypertensives at home. I've seen a number of patients w/ prescriptions, typically hydralazine or clonidine, to be taken only as needed for at home SBPs>180 (in addition to their scheduled antihypertensives). Never saw/heard of this during med school or residency and it seemingly runs counter to most everything I learned about antihypertensive management.

2) I've seen a few patients getting scheduled outpatient "infusions" of NS, usually 1-2x per week. Not talking about gomers or patients w/ short-gut, but normal functional old people. Seems somewhat wasteful, no?

Just wondering if I'm right in thinking these are kinda kooky...

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[deleted87716]

The only time I've used a prn antihypertensive (typically clonidine) is if somebody (typically an elderly female) gets really anxious when their BP is elevated, which usually makes it go even higher ("I'm afraid I'm going to have a stroke!") It's more for psychological benefit than long-term BP management. I wouldn't do it if they were going to take it frequently, however, as prn clonidine can lead to rebound hypertension. You're usually better off intensifying their daily regimen.

I've never recommended outpatient saline infusions for any reason other than dehydration from emesis or diarrhea (usually in the setting of gastroenteritis), in which case I send them to the ER rather than an infusion center. That being said, it's become something of a fad for hangovers and such (Google "infusion bars").

https://www.health.harvard.edu/blog/drip-bar-should-you-get-an-iv-on-demand-2018092814899

 

[Vandalia]

With experience in the "real world" you start to realize that medicine is at least as much "art" as "science."

To build on the previous answer, we see such patients who come to the ED whenever their blood pressure spikes a little bit. These are generally fairly rational, capable people who for whatever reason go a bit batty in this situation. Given the fairly large iatrogenic risks from an ED visit - especially today - I could see how this sort of prescription could be beneficial in some carefully selected cases.

The same with the infusion. Depending on how (if) billed, this could certainly fall into the category of insurance fraud at best. However, if this keeps a relatively healthy, independent person away from the ED (again, these places are dangerous), keeps them away from the "dwindles", then "little harm, little foul."

 

[WheezyBaby]

I've never seen "routine" crystalloid infusions outside of the spa infusion centers. I don't see how this would be reimbursed other than cash pay. The prn antihypertensive I've seen for the reasons above.

 

[Bacchus]

The only time I've used a prn antihypertensive (typically clonidine) is if somebody (typically an elderly female) gets really anxious when their BP is elevated, which usually makes it go even higher ("I'm afraid I'm going to have a stroke!") It's more for psychological benefit than long-term BP management. I wouldn't do it if they were going to take it frequently, however, as prn clonidine can lead to rebound hypertension. You're usually better off intensifying their daily regimen.

I've never recommended outpatient saline infusions for any reason other than dehydration from emesis or diarrhea (usually in the setting of gastroenteritis), in which case I send them to the ER rather than an infusion center. That being said, it's become something of a fad for hangovers and such (Google "infusion bars").

https://www.health.harvard.edu/blog/drip-bar-should-you-get-an-iv-on-demand-2018092814899

One of our former mods does something like this, I think. I think he has a "hydration bar" for all intents and purposes.

I do have one patient on outpatient saline infusions, PRN, but she has a short-gut, pseudoobstruction, and if we didn't do this she'd be in the ED and likely admitted multiple times a month.

 

[nexus73]

sorry to derail, but as a psychiatrist I see PRN buspirone for anxiety more often than you'd think... and it doesn't work that way....PRN clonidine makes more sense...for both hypertension and anxiety

 

[deleted87716]

sorry to derail, but as a psychiatrist I see PRN buspirone for anxiety more often than you'd think... and it doesn't work that way....PRN clonidine makes more sense...for both hypertension and anxiety

I have one patient who takes buspirone prn for anxiety (originally Rx'd by someone else). The patient swears that it helps. Probably a placebo effect.

 

[MedicineZ0Z]

I have one patient who takes buspirone prn for anxiety (originally Rx'd by someone else). The patient swears that it helps. Probably a placebo effect.

I think there are psychiatrists who favor this. I have not read into it.

Hey all, EM doc here and recently I've recently seen a few practices that I find a little atypical:

1) PRN anti-hypertensives at home. I've seen a number of patients w/ prescriptions, typically hydralazine or clonidine, to be taken only as needed for at home SBPs>180 (in addition to their scheduled antihypertensives). Never saw/heard of this during med school or residency and it seemingly runs counter to most everything I learned about antihypertensive management.

2) I've seen a few patients getting scheduled outpatient "infusions" of NS, usually 1-2x per week. Not talking about gomers or patients w/ short-gut, but normal functional old people. Seems somewhat wasteful, no?

Just wondering if I'm right in thinking these are kinda kooky...

Why not drink some water mixed with electrolytes. Will cost you 20 cents.

 

[turkeyjerky]

Why not drink some water mixed with electrolytes. Will cost you 20 cents.

Yeah, exactly why I made this post. It seems absolutely bonkers to me. Medical practice in this area is really weird...

 

[Bacchus]

sorry to derail, but as a psychiatrist I see PRN buspirone for anxiety more often than you'd think... and it doesn't work that way....PRN clonidine makes more sense...for both hypertension and anxiety

Not derailing. I do want to say semi related, buspirone got such a crappy reputation in my training but I’m pleasantly surprised how well it’s worked in my patients since being out on my own.

 

[Cranjis McBasketball]

Not derailing. I do want to say semi related, buspirone got such a crappy reputation in my training but I’m pleasantly surprised how well it’s worked in my patients since being out on my own.

I actually started taking buspirone about a year ago and definitely notice a difference

 

[deleted87716]

Buspirone gets a bad rap largely because it doesn't tend to work in patients who have been on benzodiazepines. As my psych attendings used to say, "Once you've had a Benz, you can't ride the bus."

 

[hallowmann]

Scheduled crystalloid outside of the few chronic conditions mentioned seems wasteful, unless there's extenuating circumstances. I've heard of it happening with a patient with cyclic vomiting syndrome (which was probably cannabinoid hyperemesis syndrome) at a smaller community hospital to prevent them from coming to the ED every week, or to manage severe hyperemesis gravidarum for the same reason when antiemetics don't work. I think I could see a justification if the argument was made that scheduled infusions would reduce ED visits, but these are special cases and far from the norm.

As for PRN antihypertensives to treat hypertension, I can't say I've seen that outside of inpatient (e.g. PRN hydralazine or labetalol for SBP/DBP > x). I have seen and prescribed plenty of propranolol PRN for anxiety, tremor, or panic attacks. Sometimes when people get admitted its labeled as "PRN for hypertension" by someone not paying attention.

Not derailing. I do want to say semi related, buspirone got such a crappy reputation in my training but I’m pleasantly surprised how well it’s worked in my patients since being out on my own.

Buspirone is great. Low risk, works really well for some (not at all for others) and is great for the people scared of side effects with psychotropics.