After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.
“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”
“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.
7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.
“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”
Going through the process while in the hospital with supervision can be a good refresher, she says.
“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.
A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.
8. Patients on steroids every day are at risk for adrenal insufficiency.
Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”
That means their bodies can’t mount an appropriate response to stress.
“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”
Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.
“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.
9. Thyroid hormone might not be as well absorbed under certain conditions.
With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”
Tom Collins is a freelance writer in South Florida.
