Diagnosis and Management of Hyponatremia and Hypernatremia

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“Hyponatremia and hypernatremia are common findings in the inpatient and outpatient settings. Sodium disorders are associated with an increased risk of morbidity and mortality. Plasma osmolality plays a critical role in the pathophysiology and treatment of sodium disorders. Hyponatremia and hypernatremia are classified based on volume status (hypovolemia, euvolemia, and hypervolemia). Sodium disorders are diagnosed by findings from the history, physical examination, laboratory studies, and evaluation of volume status. Treatment is based on symptoms and underlying causes. In general, hyponatremia is treated with fluid restriction (in the setting of euvolemia), isotonic saline (in hypovolemia), and diuresis (in hypervolemia).”

Braun
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Management of the difficult duodenal stump

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Burch JM, Cox CL, Feliciano DV, Richardson RJ, Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991 Dec;162(6):522-6.

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Abstract: Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen’s closure in 25 (13%), Bancroft’s closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen’s or Bancroft’s closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen’s and Bancroft’s closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

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Periprocedural bridging anticoagulation

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Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol. 2015 Sep 22;66(12):1392-403.

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Conclusions: Periprocedural anticoagulation management is a common clinical dilemma with limited evidence (but 1 notable randomized trial) to guide our practices. Although bridging anticoagulation may be necessary for those patients at highest risk for TE, for most patients it produces excessive bleeding, longer length of hospital stay, and other significant morbidities, while providing no clear prevention of TE. Unfortunately, contemporary clinical practice, as noted in physician surveys, continues to favor interruption of OAC and the use of bridging anticoagulation. While awaiting the results of additional randomized trials, physicians should carefully reconsider the practice of routine bridging and whether periprocedural anticoagulation interruption is even necessary.

Central Illustration. Bridging Anticoagulation: Algorithms for Periprocedural Interrupting and Bridging Anticoagulation. Decision trees for periprocedural interruption of chronic oral anticoagulation (top) and for periprocedural bridging anticoagulation (bottom). OAC = oral anticoagulation.

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Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures

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“Although the American Heart Association (AHA) and American College of Cardiology (ACC) and the American College of Chest Physicians (ACCP) provide guidelines on anticoagulation for patients with MHVs, limited guidance is provided for bridging anticoagulation 2,3 The guidelines are focused on preoperative bridging, with virtually no guidance on postoperative bridging.”

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Histological Margin Positivity in the Prediction of Recurrence After Crohn’s Resection

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“The presence of involved histological margins at the time of index resection in Crohn’s disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.“”The presence of involved histological margins at the time of index resection in Crohn’s disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.“

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