The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
HOSPITAL CARDIOVASCULAR MEDICINE
Acetazolamide in patients with diuretic-resistant heart failure (October 2022)
In patients hospitalized with acutely decompensated heart failure (HF) who are resistant to loop diuretic therapy, the safety and efficacy of augmenting diuresis with another class of diuretic agent is unknown. In a recent trial in which 500 patients hospitalized with HF and on moderate doses of an oral loop diuretic were randomly assigned to receive standardized intravenous loop diuretic therapy plus either acetazolamide or placebo, rates of death or readmission within three months were similar between the groups [1]. Rates of worsening kidney function and adverse events were also comparable between the groups, while patients receiving acetazolamide had a shorter length of stay (9 versus 10 days). In patients hospitalized with HF who are refractory to initial diuretic therapy, we increase the dose of loop diuretics before adding a nonloop diuretic to augment diuresis. (See "Use of diuretics in patients with heart failure", section on 'Refractory congestion'.)
HOSPITAL ENDOCRINOLOGY AND DIABETES
Continuous glucose monitoring for hospitalized patients with diabetes (December 2022)
Continuous glucose monitoring (CGM) is increasingly used in hospitalized patients with diabetes, but whether it offers benefit over conventional glucose monitoring remains uncertain for the inpatient setting. In a trial in 185 hospitalized adults with type 1 and type 2 diabetes on general medicine and surgery services, time spent in target glucose range (70 to 180 mg/dL [3.9 to 10 mmol/L]) and mean daily glucose did not differ between participants randomly assigned to CGM and those who underwent conventional monitoring with fingerstick and glucose meter [2]. Among participants who experienced at least one episode of hypoglycemia, CGM led to a small reduction in hypoglycemia reoccurrence. These findings demonstrate that CGM and conventional glucose monitoring yield comparable glycemic management in the inpatient setting. CGM may be beneficial in selected hospitalized patients at high risk of hypoglycemia. (See "Management of diabetes mellitus in hospitalized patients", section on 'Blood glucose monitoring'.)
HOSPITAL GASTROENTEROLOGY
Gastric protection during anticoagulation (November 2022)
Gastrointestinal (GI) bleeding can complicate anticoagulation, especially in individuals with prior GI bleeding, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and other risk factors. A new meta-analysis evaluating the benefit of proton pump inhibitors (PPIs) across six observational studies and one randomized trial found an association between PPI use and reduced upper GI bleeding (relative risk 0.67, 95% CI 0.61-0.74) [3]. The correlation was strongest in individuals with NSAIDs or aspirin use and/or with a high bleeding risk score. UpToDate contributors suggest a PPI in individuals at high risk of upper GI bleeding who require anticoagulation. (See "Risks and prevention of bleeding with oral anticoagulants", section on 'Gastric protection'.)
Fluid resuscitation in acute pancreatitis (October 2022)
Fluid therapy is central to the management of acute pancreatitis, but recommendations on the volume of intravenous fluid required have varied. In a randomized trial, 249 patients with acute pancreatitis were assigned to aggressive fluid resuscitation (lactated Ringer solution bolus of 20 mL/kg followed by 3 mL/kg/hour) versus moderate resuscitation (1.5 mL/kg/hour with a 10 mL/kg bolus in patients with hypovolemia) with subsequent goal-directed management [4]. There was no difference in rates of moderately severe or severe pancreatitis or duration of hospitalization, but the trial was terminated early due to higher rates of fluid overload in the aggressive resuscitation group (20 versus 6 percent). This study supports our approach to use moderate fluid resuscitation with goal-directed therapy in patients with acute pancreatitis. (See "Management of acute pancreatitis", section on 'Fluid replacement'.)
HOSPITAL HEMATOLOGY
IVIG for vaccine-induced immune thrombotic thrombocytopenia (October 2022)
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of adenoviral-vectored COVID-19 vaccines that presents with thrombocytopenia and thrombosis. Emerging evidence on management continues to support a role for intravenous immune globulin (IVIG) as a component of therapy, along with anticoagulation. In a new nonrandomized study involving 99 individuals with VITT presenting with cerebral venous thrombosis, receipt of IVIG was associated with lower mortality (29 versus 70 percent) [5]. In contrast, the choice of anticoagulant (heparin versus a nonheparin agent) and receipt of a platelet transfusion were not associated with statistically different mortality rates. We continue to suggest IVIG plus a nonheparin agent, especially if there is concern for possible heparin-induced thrombocytopenia (HIT; including delayed or spontaneous HIT). (See "COVID-19: Vaccine-induced immune thrombotic thrombocytopenia (VITT)", section on 'IVIG'.)
Frequency of transfusion reactions in children and adults (August 2022)
Transfusion reactions range from bothersome to life threatening. A new meta-analysis of >1.3 million transfusion reactions has documented a nearly twofold higher frequency of acute transfusion reactions in children than in adults [6]. Children were more likely than adults to have reactions to red blood cells and platelets, but not to plasma. Allergic and febrile nonhemolytic transfusion reactions were most common. The only type of reactions seen more frequently in adults were delayed hemolytic and delayed serologic reactions. Early signs and symptoms may not distinguish between benign and more serious events, and all acute transfusion reactions must be considered potentially serious until fully evaluated. (See "Approach to the patient with a suspected acute transfusion reaction", section on 'Frequency of reactions'.)
HOSPITAL INFECTIOUS DISEASES
Change in monkeypox terminology (December 2022)
In November 2022, the World Health Organization changed the name of the disease referred to as “monkeypox” to “mpox” [7]. This change was made to follow current best practices of not naming diseases after animals or geographic locations, and to reduce any stigma that could be associated with the original name. The virus that causes mpox will continue to be referred to as monkeypox virus until the International Committee on the Taxonomy of Viruses officially decides what the name of the virus is. (See "Epidemiology, clinical manifestations, and diagnosis of mpox (monkeypox)", section on 'Terminology'.)
Vaccine-derived poliovirus infection in Rockland County, New York (August 2022)
In June 2022, poliovirus was confirmed in an unvaccinated, immunocompetent adult resident of Rockland County, New York hospitalized with acute flaccid lower limb weakness [8]. Vaccine-derived poliovirus type 2 was detected in the patient's stool and was also identified from wastewater samples in two neighboring New York counties, reflecting community transmission. The patient had not traveled internationally during the presumed exposure period; therefore, these findings suggest transmission within the United States from a person who received a type 2-containing oral polio vaccine abroad. Unvaccinated individuals remain at risk for paralytic poliomyelitis if they are exposed to either wild or vaccine-derived poliovirus; all individuals should stay up to date on recommended poliovirus vaccination. (See "Poliomyelitis and post-polio syndrome", section on 'Epidemiology'.)
Role of surgery for large left-sided cardiac valve vegetation (July 2022)
Patients with left-sided native valve infective endocarditis with a large (>10 mm) vegetation are at high risk for mortality, but a benefit from early valve surgery in this setting has not been established. An observational study of over 700 patients with left-sided infective endocarditis found that although patients with large vegetations had a high early mortality rate, vegetation size was not an independent predictor of mortality [9]. Among patients with large vegetations without heart failure or uncontrolled infection, the mortality rate was similar with or without valve surgery. For patients with large vegetations, we perform an individualized risk-benefit assessment comparing early surgery with expectant management based upon multiple factors including response to antibiotic therapy, presence of embolic events, and surgical risk. (See "Surgery for left-sided native valve infective endocarditis", section on 'Vegetation characteristics and risk of embolization'.)
HOSPITAL NEUROLOGY
Delayed functional improvement after intracerebral hemorrhage (September 2022)
Functional improvement after intracerebral hemorrhage (ICH) can be slow and the temporal trajectory is often uncertain. In an analysis of individual patient data from two clinical trials in nearly 1000 patients with intracerebral or intraventricular hemorrhage, 72 percent of patients had a poor functional outcome at 30 days [10]. By one year, 46 percent had recovered further and achieved a good functional outcome, including 211 (30 percent) who were functionally independent. Acute ICH complications such as sepsis, new ischemic stroke, prolonged mechanical ventilation, hydrocephalus, and the need for a gastrostomy feeding tube were predictors of poor outcome at one year. These results support the practice of providing aggressive acute treatment of patients with ICH and sustained rehabilitation to help avoid premature withdrawal of support and improve long-term outcomes. (See "Spontaneous intracerebral hemorrhage: Secondary prevention and long-term prognosis", section on 'Functional recovery'.)
Updated diagnostic criteria for cerebral amyloid angiopathy (August 2022)
For patients presenting with acute intracerebral hemorrhage, the Boston criteria have been used to specify diagnostic certainty of cerebral amyloid angiopathy (CAA) based on specific hemorrhagic findings. However, the criteria did not address nonhemorrhagic presentations of CAA. Updated Boston criteria (version 2.0) for sporadic CAA now encompass hemorrhagic and nonhemorrhagic presentations and include expanded imaging findings (cortical microbleeds and white matter features) (table 1) [11]. In a retrospective, multicenter review of 341 patients who presented with clinical features consistent with CAA and had both magnetic resonance imaging and brain tissue available for analysis, the Boston criteria version 2.0 produced a higher diagnostic accuracy for probable CAA than the previous modified Boston criteria (85 versus 80 percent) while retaining high specificity (95 percent for both). These results support the utility of these updated criteria to identify patients with CAA. (See "Cerebral amyloid angiopathy", section on 'The Boston criteria for CAA'.)
HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE
Aspirin versus enoxaparin to prevent venous thromboembolism after hip or knee arthroplasty (September 2022)
The role of aspirin as a sole agent for venous thromboembolism (VTE) prophylaxis in adult patients undergoing total hip or knee arthroplasty (THA, TKA) is debated. In a recent, randomized crossover trial of over 9700 patients following THA or TKA that compared aspirin (100 mg orally per day) to enoxaparin (40 mg subcutaneously per day), symptomatic distal deep vein thrombosis was more common in patients receiving aspirin (2.4 versus 1.2 percent) [12]. There was no difference in the rates of major bleeding (< 0.5 percent) and death. Study limitations include the trial being stopped early for harm and lack of blinding of hospitals to treatment allocation. Nevertheless, these findings indicate that aspirin alone is inferior to enoxaparin and supports our practice of not using aspirin as the sole agent for VTE prophylaxis in patients following THA or TKA. (See "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement", section on 'Aspirin'.)
Dexmedetomidine and delirium in critically ill patients (August 2022)
Data have been conflicting regarding clinical benefit associated with dexmedetomidine as a sedative in critically ill patients. A recent meta-analysis of 77 randomized trials (almost 12,000 patients) reported that compared with other sedatives, dexmedetomidine reduced the risk of delirium (relative risk 0.67, 95% CI 0.55-0.81; moderate certainty) but increased the risk of bradycardia and hypotension [13]. We agree with a recent guideline committee that dexmedetomidine can be successfully used as a sedative when the goal of reducing delirium is outweighed by the undesirable effects of hypotension and bradycardia [14]. (See "Sedative-analgesic medications in critically ill adults: Properties, dose regimens, and adverse effects", section on 'Efficacy'.)
Intravenous magnesium in severe COPD exacerbation (August 2022)
Intravenous magnesium has short-acting bronchodilator activity that is helpful for severe asthma attacks, but it has not previously been recommended for chronic obstructive pulmonary disease (COPD). A new systematic review and meta-analysis found a decrease in hospitalization rates with emergency department intravenous magnesium administration compared with placebo [15]. The effect size is similar to or better than that seen in the setting of asthma exacerbation. Based on these data, we now suggest intravenous magnesium for patients with severe COPD exacerbations who are not improving with inhaled bronchodilator therapy. (See "COPD exacerbations: Management", section on 'Magnesium sulfate'.)
De-escalation of fluid therapy in sepsis (June 2022)
In patients with sepsis, there is little guidance regarding when and how intravenous fluids (IVF) should be de-escalated following initial resuscitation. In a recent trial of over 1500 adults with sepsis who had received at least 1 liter of fluid and were within 12 hours of the onset of shock, individuals assigned to restrictive IVF strategy (ie, infusion stopped; small boluses given when needed for organ perfusion, low urine output, or insensible losses) compared with a standard IVF strategy had similar 90-day mortality and adverse effects [16]. These data support the safety of a restrictive approach to fluid de-escalation. However, the volume of fluid in both groups was lower than that previously reported in early resuscitation sepsis studies suggesting that practice has evolved toward a de-escalation approach that is restrictive. More studies are needed to further guide postresuscitation fluid therapy in patients with sepsis. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'De-escalation fluids'.)
Vitamin C alone not effective in sepsis (June 2022)
Early observational evidence suggested a possible mortality benefit from intravenous (IV) vitamin C in combination with thiamine and hydrocortisone in patients with sepsis. However, several randomized trials have since reported a lack of benefit from this combination. A recent trial of 872 patients with septic shock (and on a vasopressor) has reported that IV vitamin C alone also had no effect on 28-day mortality (35 versus 32 percent) or persistent organ dysfunction (9 versus 7 percent) [17]. One patient had severe hypoglycemia and another had anaphylaxis in response to vitamin C. We continue to recommend against the routine use of vitamin C alone or in combination with thiamine or hydrocortisone. (See "Investigational and ineffective therapies for sepsis", section on 'Vitamin C'.)
Routine preintubation fluid bolus does not prevent cardiovascular collapse in critically ill adults (June 2022)
Hypotension occurs in up to 50 percent of critically ill patients during and after intubation, and can cause cardiac arrest. If time permits, preintubation hemodynamic optimization is recommended, including correction of hypovolemia. However, in a randomized multicenter trial in >1000 critically ill adults, routine administration of a 500 mL intravenous (IV) fluid bolus prior to intubation did not reduce the incidence of cardiovascular collapse compared with no fluid bolus [18], consistent with a previous smaller trial. Methods to reduce peri-intubation hypotension should be individualized and may include use of etomidate or ketamine for induction, use of vasopressors, and IV fluid if necessary. (See "Complications of airway management in adults", section on 'Hemodynamic changes'.)
