Treating the Numbers

[jon62781]

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I guess I missed the lecture in school about "treating the numbers"

It seems many of my colleagues, and several posters to SDN, have adopted a theory that you don't treat a patient's condition (HTN, Anemia, etc) unless they are having symptoms.... Am I wrong, or does this not always make sense?

I mean, there is a post on here about treating HTN Urgency on call:

Are you telling me that you are actually okay with patients sitting at 170-180 just because they aren't symptomatic. I thought those symptoms were what we were attempting to avoid, namely stroke, MI, renal damage. Just because they don't have blurry vision, massive chest pain or a headache, that doesn't make 180/95 less dangerous.

And what about HgB..... One of my colleagues actually scolded me (I know) for wanting to transfuse someone low 8's. "they aren't symptomatic" While some do develop ShOB or weakness, how do we know they aren't going straight to flippin their T's? I understand if someone lives at the 8's chronicly, but if you come to me previously healthy and you HgB is 8.2, I am not waiting for symptoms, you are getting some extra gas in the tank.

Thanks for the opportunity to vent.......

Now someone can tell me how wrong I am!

 

[Bertelman]

And what about HgB..... One of my colleagues actually scolded me (I know) for wanting to transfuse someone low 8's. "they aren't symptomatic" While some do develop ShOB or weakness, how do we know they aren't going straight to flippin their T's? I understand if someone lives at the 8's chronicly, but if you come to me previously healthy and you HgB is 8.2, I am not waiting for symptoms, you are getting some extra gas in the tank.

You should read the literature discussing transfusion goals. Also remember blood transfusions aren't magical elixirs that are free of side effects or complications. There are good reasons why consent is required prior to transfusion. In general, you should have a very compelling reason to transfuse someone with a Hb >8. After some time, you will become accustomed to seeing Hb ~8 in many inpatients. If they all got transfused, you'd empty the bank.

 

[Winged Scapula]

As others have pointed out, there is recent clear data to support transfusion only for Hgb less than 7 (or 10 in patients with CAD hx). A restrictive transfusion policy is not only safer but economical as well.

The point about symptoms in the other thread was not that we don't treat patients unless they are symptomatic but to question what our goal is when we treat patients. Most of us will have periods when our VS, lab work, etc. are outside of "call order/normal range."

Especially for those of us in surgical fields, we often see patients with high blood pressures or heart rates that are technically outside of normal range, but effectively are common and do not cause any problems. Treating isolated HTN in a post-op hospitalized patient is not necessary. If the patient has uncontrolled hypertension with symptoms, that's a different story but random variations in VS do not warrant treatment and there is no evidence that treating "numbers" in most of these cases results in any benefit to the patient.

 

[BADMD]

Are you telling me that you are actually okay with patients sitting at 170-180 just because they aren't symptomatic. I thought those symptoms were what we were attempting to avoid, namely stroke, MI, renal damage.

Just to add to Tired's comment: if you give short acting agents, you have only delayed the issue for 6 hours. Asymptomatic hypertension is a chronic issue and should be handled chronically. That is why acute presentations are divided into urgency and emergency. Urgency is supposed to be controlled over 2 or so weeks. American College of Emergency Physician guidelines do not suggest admission nor starting medications for people with hypertensive urgency if they have ready access to primary care.

What we know you can do is cause strokes by underperfusing a brain that is used to an elevated blood pressure. IV vasoactive agents are quite powerful and should be used when you expect benefit. While docs love to buff the chart, what we are really doing is treating ourselves and not patients.

And what about HgB..... One of my colleagues actually scolded me (I know) for wanting to transfuse someone low 8's. "they aren't symptomatic" While some do develop ShOB or weakness, how do we know they aren't going straight to flippin their T's? I understand if someone lives at the 8's chronicly, but if you come to me previously healthy and you HgB is 8.2, I am not waiting for symptoms, you are getting some extra gas in the tank.

There is a growing body of literature that suggest significant potential for morbidity associated with blood transfusions. Approximately 1 in 100 will have some sort of transfusion reaction. Additionally, your patients aren't getting nice fresh happy blood. They get the oldest blood on the shelf. The oxygen carrying capacity isn't particularly high, it has lots of 2,3 DPG, the cells are fragile, and there is a very high volume load associated with transfusion.

There are a few studies looking at conservative versus aggressive transfusion strategies. As far as I know, virtually all of them have shown the conservative works as well as the aggressive and some have shown fewer complications. One study showed a higher pneumonia rate in those with the liberal transfusion strategy, so the complications may be further reaching that we think.

Just a story that drove this home for me: I was called to consult (for an unrelated reason) a few months ago on a young woman who came to the hospital for a semi emergency D&C for uterine bleeding. Her hemoglobin hit 8.2 and since a unit of blood was in the OR and she had already been cross matched, they decided to give it. She developed TRALI very rapidly and could be not be extubated. When I saw her several months after her surgery (still hospitalized) she was trached/PEGed and had several episodes of severe sepsis/septic shock. It all started from 1 unit of blood that she probably didn't need. One bad outcome? Yes, but it certainly was enough to make me think twice before ordering blood.

As for "flipping T waves," without elevations in troponins or symptoms, I'm not sure what flipped T waves mean, besides that the ECG is abnormal.

One of the surgeons I worked with before finishing residency said that he wouldn't transfuse anyone who wasn't bleeding and was stable. I've started to subscribe that that philosophy.

 

[DOctorJay]

don't live and die by the lab, remember the concept of coefficient of variance. for example the coefficient of variance of Hgb at one of my hospitals is 1.0. That means someone can have a lab value of Hgb at 8.0 but in reality be 8.5 to 7.5 (at least this is how our pathologist explained it to us). If no symptoms repeat the test if you can.

 

[nitemagi]

On the other hand, if in the hospital you start getting abnormal vitals or labs, knowing the persons baseline...you might not treat but you should at least investigate. Had a girl the other day suddenly spike a fever 103ish and get tachy in the 130's. On psych inpt, I was cross-covering. I ordered the usualy workup, most of which was negative, and I did a thorough exam. If I hadn't looked into it, I wouldn't have caught the clonus in her feet and that she was developing a serotonin syndrome.

 

[oompaloompa]

Another moral to this story is don't just check lytes unless you have a specific reason or plan(IVF, TPN, dehydration, OR, etc.) Sure, most people will have normal lytes and its reassuring, but are you really going to supplement that potassium of 3.0 on a pt eating normal diet. Really?

 

[Blade28]

Great point.

In most situations in medicine (and this can be extrapolated to life, for that matter), why order a lab/study if its results aren't going to potentially change your management?

 

[edmadison]

Great point.

In most situations in medicine (and this can be extrapolated to life, for that matter), why order a lab/study if its results aren't going to potentially change your management?

Fantastic advice. The big point here and that the OP needs to understand is that numbers aren't the end all and be all of medicine. Treating a patient just because you don't like the number is bad medicine. Getting bogged down in numbers and forgetting the big picture is a frequent criticism of IM. As others have posted, interventions have side effects too and should not be ignored. Further, if you treat the number (K+ is low, give more K+) you might miss why the K+ is low. In peds, we see this sometimes when non-pediatricians are managing kids as adults.

Example 1:

Call from GS resident: How much insulin do I give a 2-year old with hypoglcemia?
Me: Uh, How high is her glucose?
Him: 195?
Me: Uh, probably none, what fluids is she on.
Him: Well I already gave her x units twice and it's still elevated. She's on D5 1/2 NS at 2x maintenance.
Me: Well, in effect you're giving her maintenance with D10, just decrease the amount of D and her BG will come down pretty quickly. Just be careful that she doesn't bottom out.

Example 2:
Call from different GS resident: How much K+ should I give this 8 year-old who had an appy yesterday.
Me: Uh, what's the K+?
Him: 2.8
Me: Any symptoms?
Him: No
What fluid is he on?
Him: D5 1/2 NS
Me: 2.8 is ok, just put K+ in him maintenance and keep and eye on him.

Ed

 

[ekydrd]

...
Example 1:

Call from GS resident: How much insulin do I give a 2-year old with hypoglcemia?
Me: Uh, How high is her glucose?
Him: 195?
Me: Uh, probably none, what fluids is she on.
Him: Well I already gave her x units twice and it's still elevated. She's on D5 1/2 NS at 2x maintenance.
Me: Well, in effect you're giving her maintenance with D10, just decrease the amount of D and her BG will come down pretty quickly. Just be careful that she doesn't bottom out.

...Ed

Not to be picky or anything but I think you meant hyperglycemia

 

[ekydrd]

Good thing you popped in 4 days after his post to point that out. Very helpful, thank you.

Glad to help😛

 

[edmadison]

Not to be picky or anything but I think you meant hyperglycemia

Oh crap, this explains why all of my diabetic patients have done so poorly over the past 4 years.

😀

Ed

 

[ekydrd]

Oh crap, this explains why all of my diabetic patients have done so poorly over the past 4 years.

😀

Ed

Glad to be of service.😉