Bedside Manner 2020: An Inventory of Best Practices.

Bedside manner, a doctor's deportment with a patient, encompasses all aspects of the patient interaction, including all verbal and nonverbal communication strategies. Bedside manner can be a powerful adjunct for healing. In academic medical centers, trainees generally learn bedside manner by observing their attendings and mentors-in other words, as part of the "hidden curriculum." Because bedside manner is a critical component in the art of healing, it can be threatened by pressures on time in managing inpatients and by the explosion of technology. This article assembles an inventory of best bedside practices for inpatient care. Eight best bedside practices were identified by reviewing the literature, collecting the personal experiences of the authors, and consulting a group of attendings whom the authors regarded as exemplary clinicians. This inventory is presented with the goal of expanding clinicians' repertoire of best practices and encouraging explicit teaching of these practices to optimize care.

Effect of Anemia on Mortality in Mechanically Ventilated Patients With Chronic Obstructive Pulmonary Disease.

RATIONALE: The effect of anemia on patients with chronic obstructive pulmonary disease (COPD) requiring invasive mechanical ventilation for acute respiratory failure is unknown. OBJECTIVES: To examine the association between anemia (hemoglobin <12 g/dL) and 90-day and overall mortality in patients with COPD having acute respiratory failure requiring invasive mechanical ventilation. METHODS: Retrospective study of patients admitted to a quaternary referral medical intensive care unit (ICU) between October 2007 and December 2012 with a diagnosis of COPD and requiring invasive mechanical ventilation for acute respiratory failure of any cause. RESULTS: We identified 1107 patients with COPD who required invasive mechanical ventilation for acute respiratory failure. Mean age was 64.2 ± 12.7 years; 563 (50.9%) were females. The mean Acute Physiology and Chronic Health Evaluation III score at ICU admission was 80.5 ± 29.3. The median duration of mechanical ventilation was 35.7 hours (interquartile range: 20.0-54.0). In all, 885 (79.9%) patients were anemic (Hb < 12g/dL) on ICU admission, and 312 patients (28.2%) received blood transfusion during their ICU stay. A total of 351 inhospital deaths were recorded, the majority (n = 320) occurring in the ICU. The 90-day mortality, though lower in the nonanemic patients compared to the patients with anemia, was not statistically significant (35.6% vs 44.9%; hazard ratio [HR] [95% confidence interval; CI] = 1.16 [0.91 -1.48], P = .22). The overall mortality was lower in the nonanemic patients compared to patients with anemia (HR [95% CI] = 0.68 [0.55-0.83], P < .001). There was a 5% decrease in risk of death for every unit increase in hemoglobin (P = .01). There was no difference in terms of both 90-day and overall mortality in patients who received blood transfusions compared to patients who did not receive any transfusion. CONCLUSIONS: Critically ill patients with COPD requiring invasive mechanical ventilation for acute respiratory failure without anemia on admission had a better overall survival when compared to those with anemia. No difference was noted in the 90-day mortality. Further studies are needed to determine the impact of the trajectory of hemoglobin on mortality.

Management of antithrombotic agents in patients undergoing flexible bronchoscopy.

Bleeding is one of the most feared complications of flexible bronchoscopy. Although infrequent, it can be catastrophic and result in fatal outcomes. Compared to other endoscopic procedures, the risk of morbidity and mortality from the bleeding is increased, as even a small amount of blood can fill the tracheobronchial tree and lead to respiratory failure. Patients using antithrombotic agents (ATAs) have higher bleeding risk. A thorough understanding of the different ATAs is critical to manage patients during the peri-procedural period. A decision to stop an ATA before bronchoscopy should take into account a variety of factors, including indication for its use and the type of procedure. This article serves as a detailed review on the different ATAs, their pharmacokinetics and the pre- and post-bronchoscopy management of patients receiving these medications.

Predictors of mortality after transjugular portosystemic shunt.

AIM: To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt (TIPS) can provide prognostic information that will enhance risk stratification of patients. METHODS: We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution. We recorded information regarding patient demographics, underlying liver disease, indication for TIPS, baseline laboratory values, hemodynamic determinations at the time of TIPS, and echocardiographic measurements both before and after TIPS. We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations. We also calculated Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) class. The following pre- and post-TIPS echocardiographic determinations were recorded: Left ventricular ejection fraction, right ventricular (RV) systolic pressure, subjective RV dilation, and subjective RV function. We recorded the following hemodynamic measurements: Right atrial (RA) pressure before and after TIPS, inferior vena cava pressure before and after TIPS, free hepatic vein pressure, portal vein pressure before and after TIPS, and hepatic venous pressure gradient (HVPG). RESULTS: We reviewed 418 patients with portal hypertension undergoing TIPS. RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmHg (P < 0.001), HVPG decreased by 6.8 ± 3.5 mmHg (P < 0.001). In multivariate linear regression analysis, a higher MELD score, lower platelet count, splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure (R = 0.55). Three variables predicted 3-mo mortality after TIPS in a multivariate analysis: Age, MELD score, and CTP grade C. Change in the RA pressure after TIPS predicted long-term mortality (per 1 mmHg change, HR = 1.03, 95%CI: 1.01-1.06, P < 0.012). CONCLUSION: RA pressure increased immediately after TIPS particularly in patients with worse liver function, portal hypertension, emergent TIPS placement and history of splenectomy. The increase in RA pressure after TIPS was associated with increased mortality. Age, splenectomy, MELD score and CTP grade were independent predictors of long-term mortality after TIPS.

New Nodule-Newer Etiology.

AIM: To evaluate frequency and temporal relationship between pulmonary nodules (PNs) and transbronchial biopsy (TBBx) among lung transplant recipients (LTR). METHODS: We retrospectively reviewed 100 records of LTR who underwent flexible bronchoscopy (FB) with TBBx, looking for the appearance of peripheral pulmonary nodule (PPN). If these patients had chest radiographs within 50 d of FB, they were included in the study. Data was compared with 30 procedures performed among non-transplant patients. Information on patient's demographics, antirejection medications, anticoagulation, indication and type of lung transplantation, timing of the FB and the appearance and disappearance of the nodules and its characteristics were gathered. RESULTS: Nineteen new PN were found in 13 procedures performed on LTR and none among non-transplant patients. Nodules were detected between 4-47 d from the procedure and disappeared within 84 d after appearance without intervention. CONCLUSION: FB in LTR is associated with development of new, transient PPN at the site of TBBx in 13% of procedures. We hypothesize that these nodules are related to local hematoma and impaired lymphatic drainage. Close observation is a reasonable management approach.