Grand Rounds - April 6, 2016

• GU/Renal Board Review
• Abdominal Ultrasound for Free Air
• Urinary Retention
• Contrast Induced Nephropathy
• Tox: Iron overdose

GU/Renal Board Review – by Stefanie Gilbert

• Priapism
  • Tx:
    • corporeal aspiration – 2' and 10’o’clock
    • IV /IM terbutaline works 30%
    • intracorporeal phenylephrine
    • icepacks
  • low-flow is painful
  • high-flow is painless
  • Causes:
    • SCD
    • trazadone (traza-bone)
    • Compazine, thorazine (given w hiccups)
    • high-flow is generally caused by spinal cord injury (usu cervical)

• Prostatitis
  • MCC:
    • >35 yrs old: E. coli
      • Tx: fluoroquinolone or TMP-SMX – long courses 30 days
    • <35 yrs old: gonorrhea & chlamydia
      • Tx: CFX and Doxy – long course 30 days
  • aggressive rectal exam can seed bacteria

Ring Down

• Indications for emergent HD:
  • A – severe acidosis
  • E – electrolyte problems (refractory or rapidly rising K+, hyperphosphatemia >10)
  • I – intoxicants (ISTUMBLED)
    
    • Isopropyl alcohol, INH (give B6 in overdose)
      
    • Salycilates
      
    • Theophylline
      
    • Uremia
    • Methanol
    • Barbiturates
      
    • Lithium
      
    • Ethylene glycol
      
    • Depakote, dabigatran (Pradaxa)
      
  • O – overload: e.g. pulmonary edema (even if responsive to NTG, etc.)
• • U – uremia (elevated BUN (typically >100) with sx’s (pericarditits, bleeding, AMS)

• Tx for uremic pericarditis – emergent HD

• UTI
  • cultures on pts with comorbidities (but not young, otherwise healthy)

• Renal stones
  • MC site: ureterovesicular junction(UVJ)
  • MC type: calcium oxaloate
  • Uric acid stones are radiolucent on XR
  • stones <5mm: likely to pass spontaneously w/in 4wks
  • stones >8mm: unlikely to pass

• Kidney Transplant
  • Rejection:
    • hyperacute -  in OR by preformed Abs (will not see in ER)
    • acute – up to 3 months
      • sx
        • incr Cr (>20%, even if in normal range)
        • fever
        • proteinuria
      • Tx:
        • renal US to check flow
        • call transplant team
    • chronic – 3 months+
      • insidious progression
      • fibrosis/scarring, ischemia, organ death

• Balanitis (inflammation of glans)/Posthitis (inflammation of distal foreskin)/ Balanoposthitis
  • usually fungal – give antifungal cream
  • if STDs suspected, tx as such

• Hydrocele
  • painless
  • R > L
  • transilluminates
  • ultrasound
  • a/w inguinal hernia
  • in babies, give up to a year for it to self-resolve

• Spontaneous Bacterial Peritonitis
  • if VSS and otherwise well, can manage w outpt intraperitoneal abx
  • rarely need to change PD catheter
  • WBC >100 in peritoneal fluid

• Epididymitis
  • will have incr blood flow to testicle (vs torsion)
  • STD is younger pts
  • Friend sign: raising testicle in epididymitis decreases pain

• Bladder Cancer
  • 2nd MC GU cancer (prostate 1st)
  • MC presenting sx: painless hematuria
  • RFs: smoking, aniline dye
  • usually transitional cell carcinoma

• Paraphimosis
  • foreskin cannot be reduced
  • vascular emergency
  • Tx: manual reduction
  • if reduction fails -> dorsal slit procedure

• Blood at urethral meatus
  • needs retrograde urethrogram (RUG)
  • can also see hematoma in scrotum or perineum

 
 
Ultrasound: Air Where it Shouldn’t Be – by Sean Chester

• Sign of intraperitoneal free air:
  • Pneumoperitoneum
    • US more sensitive than x-ray (93% vs 79%) (specificity of 67%)
    • start epigastric and scan to RUG
  • Ring Down effect
    • hyperechoic line down from air bubble (line narrow B line)
  • Dirty fluid

• Necrotizing Fasciitis
  • Findings:
    • soft tissue thickening
    • fluid pockets in deep fascial structures
    • posterior shadowing of air in tissue
    • A line in soft tissue (rare, but very bad)
  • sensitivity 885 ; specificity 93% 

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Tox Bit – by Dr. Clancy

• Of note, deferoxamine is a/w ARDS

Contrast-Induced Nephropathy – by Aziz Almehlisi

• Historical reports of contrast-induced nephropathy
• Contrast has changed – we now use low-osmolar contrast
• We know that intra-arterial contrast is a/w CIN
• 2007 Review in Radiology
  • 3000+ studies
  • only 2 with control groups
    • no difference in AKI in con vs non-con groups (even in study using hyperosmolar contrast!)
• 2014 study
  • no difference in AKI in con vs non-con groups
  • some pts in con group even had decreased in Cr!
• Does incr in Cr even mean AKI?
  • eGFR is better measurement (though that just uses age and Cr)
• “Flushing” with hydration after contrast
  • studies show NS is better than Lasix and mannitol
  • bicarb may be protective, but studies are methodologically flawed (ACR does not endorse or rec against)
• Pts on metformin are not at higher risk of CIN – no reports of lethal lactic acidosis
  • however, ACR recs holding metformin before imaging if:
    • AKI
    • severe CKD
    • intra-arterial study
• GW policy will be:
  • contrast ok if GFR > 40
  • consent and hydrate if GFR 30-40
  • contraindicated if GFR < 30

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Specialty Conference: Acute Urinary Retention (AUR) – by Raj Gadhia
with guest speaker Alice Semerjian (urology PGY-5)
​

• Definition of AUR: inability to pass urine voluntarily even when urine is present
• Incidence
  • >10% of men >70
  • 1/3 of men >80
  • F:M ratio 1:13
• Can lead to obstructive renal failure

• 5 Main Causes
  • neuro
    • upper motor neuro
      • MS
      • CVA
      • tumors
    • lower motor neuro
      • trauma
    • DM neuropathy
  • drug
    • alpha, NSAIDs, opioids, amitryptilene, anticholinergics
  • infection
    • urethritis, cystitis, prostatitis, vulvovaginitis, viral causes
  • obstructive
    • intrinsic – prostate, stone
    • extrinsic – mass, pregnancy (typically in impacted, retroverted uterus)
  • other
    • post partum
    • trauma
    • psychogenic (“shy bladder”)
    • psychoactive (ecstasy, meth)

• DRE
  • finger often underestimates prostate volume
  • if you are lucky enough to feel a “high-riding prostate”, check meatus for blood, consider RUG
• Labs
  • UA, U cx, BMP, +/-CBC, U preg
• Value of Ultrasound
  • stone
  • obstructions
  • free fluid from trauma
  • bladder mass
  • bladder volume/post-void residual
  • check catheter placement
• Post void Residual
  • Normal <100
  • 300-400, get renal US
  • Formula – L x W x H x 0.5 (some say 0.75, which slightly overestimates)
• Decompression
  • contraindications: blood at meatus, mass, high-riding prostate
  • sometimes going bigger helps get through obstructions (18+ in known BPH)
  • can use UroJet – viscous lidocaine you squirt into urethra before attempt

1. Straight tip
2. Coude tip (for obstruction at prostate) 
3. 3-way catheter for irrigation (use in adults w gross hematuria)​

• Trapped Foley
  • sometimes adding back 1cm water (should not use saline b/c can crystalize) to remove balloon ridge
• Foley removal
  • ~1-2 weeks depending on cause
• Treatment
  • prophylactic abx and Foley
  • abx course for prostatitis – 30 days
  • alpha block (doxazosin, tamsulosin)
  • 5 alpha reductase (finasteride)
    • takes weeks to begin effect
    • affects PSA levels
    • better started by outpt specialist
• Post-Obstructive Diuresis
  • At risk:
    • CHF...
  • Monitor and recheck electrolytes
• Refer to specialist:
  • Men <45
  • abnl prostate
  • hematuria
  • post-void residuals
  • hx strictures
  • hx neurogenic bladder
• How to help Urology
  • document post-void residual
  • counsel about emptying legs bags and not reattaching upside down!
• Suprapubic catheters
  • Recommended video: https://www.youtube.com/watch?v=3C-dBru73-E&feature=youtu.be
  • Other video: http://emedicine.medscape.com/article/145909-overview#a7
  • SPCs (or SP tubes – SPTs) are changed just like Foleys when tract is matured
• warn of postural hypoTN w aplpha blocker
• urination is not always resolution – could be overflow

 
 
King of the Hill: Legislation for Dummies – by Todd Clark

• Speakers for next week’s Hill Day:

• Patient Protection and Affordable Care Act (ACA or “Obama Care”)
  • Crafted to get most revenue-neutral scoring from CBO
  • Very similar to Nixon-proposed health care reform (Ted Kennedy helped kill the bill)
  • Individual mandate upheld by Supreme Court as tax instead of as government regulation
    • tax has been deferred until this year, so we’ll see if it’s effective in motivating people to enroll
  • Some large insurance companies (e.g. United Healthcare) have dropped out of the insurance market exchanges b/c they said they can’t make money
  • Individual state insurance exchanges – many have failed, others are on probation
  • Young Invincibles are not enrolling (therefore increasing the risk of the pool of people enrolled)
    • Concern for Death Spiral – healthier people dropping out as cost of insurance goes up
  • 11 million people currently enrolled under the ACA
  • ACA provided for PCORI (comparative effectiveness research institute) – but compromised with PhRMA and insurance companies: cannot use this information to influence the way the government spends money on health care
  • Other ACA provisions
    • minimum basic coverage of plans
    • caps on premiums (older, sicker pts have premiums limited to a certain multiple of young, healthy pts)
    • children covered under parents’ insurance up to age 26
    • no more prohibition for preexisting conditions
    • no more caps on lifetime benefits for catastrophic coverage

• Congressional Budget Office (CBO)
  • Executive branch uses Office of Management and Budget (OMB) for projections of impact of policies
  • In 1970’s, Congress formed CBO to do the same for it (given concern about OBM bias toward presidential agenda)
  • CBO calculates how much (certain) proposed bills will cost: 5- and 10-year projections, including
    • mandatory spending
    • discretionary spending
  • Chair of CBO is appointed by Senate and House Budget Committees
    • In order to preserve non-partisan position, the CBO does not make policy recommendations, only crunches numbers
  • CBO is only allowed to calculate direct financial impact of bills, not the implications of those costs (e.g. can calculate cost of buying treadmills funded by government, but not decreased cost of health care for those healthier people)
    • scoring is based on current expenditures (will the new bill cause more spending, or less?)

• Opioids
  • stop opioid abuse
  • buprenorphine + naloxone = suboxone
    • limit on # of  pts each prescriber can have
    • extensive/burdensome training for prescribers