Just Stop

So this is going to be a recurrent section about things in medicine that need to stop being done, and for whatever reason grate on my nerves more than all of the other things that we do that need to stop being done. Today's topics, orthostatics and bowel sounds.

Orthostatics: what is the definition med students? That's right, a systolic blood pressure drop of 20mmHg or a diastolic blood pressure drop of 10mmHg or an increase in heart rate of 20 beats/min. Now, here is why that's wrong. Way back 20 years ago, in JAMA Rational Clinical Exam Article (great series btw, for anyone that hasn't used it), published some data about both children and adults with hypovolemia, they updated it about 10 years later and put it into a book. What did they have to say? A 20 point drop in SBP happens in 10% of everyone when they stand, and up to 30% of those over 65, in OTHERWISE HEALTHY INDIVIDUALS. They also usually have a 10 beat/min increase in heart rate, although this goes away after about 60 seconds. The best cutoff appears to be a 30 beat/min increase from laying to standing. And while they did cite one study that seemed to support the drop in systolic BP and at least 3 that say it's not valuable (not as many studies as you thought, huh? Which probably means there's some room for argument, but I would say the literature mostly says it's unhelpful. This study in normovolemic adolescents, showed the average systolic blood pressure change was 19 to -17mmHg. Just know, lots of older folks will want you to get orthostatic measurements, but are they helpful? Unlikely.

Bowel sounds: another long held practice that is based on....well, nothing really, as it turns out. Again, one study found bowel sounds useful for bowel obstruction. But this one, and this one disagree, this one and this one argue they're also not helpful after surgery, and this In Practice from NEJM argues it should probably be done away with. So, and again, you will still be responsible for reporting them to your ancient attending, but should you base any management on your findings? The evidence would suggest not.

And that's it for this installment. Future installments will probably include things like heparin TID, IVF more hypotonic than 1/2 NS, and the idea that atelectasis causes fever.