Ravi Singh Profile picture
Sep 25, 2020 14 tweets 6 min read Read on X
1/Why does the Hg/Hct drop in the first two days during hospitalization ?
We'll explore this issue in this short #medtweetorial
#medtwitter #FOAMed #MedStudentTwitter
2/Interestingly , anemia of hospitalization is commonly thought to be due to
- phlebotomy
- IVF
- invasive procedures/ bleeding etc

However, prolonged bed rest can contribute to a drop in your pts blood count !
Another reason to get our patient's out of bed if possible !
3/Until the mid-20th century, bedrest was considered a benefit that helped people heal. Hippocrates had already noted the risk of loss of muscle, bone and tooth(Chadwick and Mann, 1950)
Today, there is recognition of bedrest’s negative effects on body and the blood volume.
4/ In WW2, , when forced to mobilise quickly soldiers recovered more quickly from injuries and infections. Aeronautics research confirmed that prolonged immobility/weightlessness was detrimental to health, adversely affecting all major organs
5/Over 120 years ago, Ernest Starling demonstrated that fluids and other molecules move back and forward from blood to the extravascular space.
6/This movement is determined by the balance between hydrostatic and oncotic pressures acting within capillaries and interstitial spaces
7/In 1928, a 32-page long paper in the Journal of Clinical Investigation elegantly demonstrated that total plasma volume decreases on average 11% after 30 min standing still, compared to the recumbent position, and that hematocrit increased proportionally.
ncbi.nlm.nih.gov/pmc/articles/P…
8/ 30 years later, another study described a decrease in plasma volume of 10.8% (equivalent to around 500 mL in a 70 kg adult) after 15 min. This change was completely reversed after lying down again, with a mean increase in total plasma volume of 12.5% in healthy subjects.
9/These shifts of total plasma volume were accompanied by inverse changes in hematocrit, which increased 6.6% after one hour of standing, and decreased 7.0% after resuming the horizontal position.
ncbi.nlm.nih.gov/pmc/articles/P…
10/ Other reasons for Hg drop on the first hospital day was due to admission phlebotomy/ blood work, hemoconcentration/volume depletion in acutely ill people, and the initiation of IVF
ncbi.nlm.nih.gov/pmc/articles/P…
11/ Therefore, the knowledge that up to 30% of variations in total plasma volume can be attributed solely to lying down should certainly influence our posture and our reasoning during clinical evaluations.
12/ In conclusion, prolonged rest can cause a Hg drop and contribute to anemia of hospitalization.
Unfortunately, even today, patients aged 65 years and over can spend 71-83% of their time in hospital lying down (Fox et al, 2018).
It's time to end this ‘pyjama paralysis’ !
Postural Pseudoanemia !
sciencedirect.com/science/articl…
Summary slide updated with suggestions from #MedTwitter. Thank you for the suggestions.

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More from @rav7ks

May 6, 2022
1/8
You start SQ insulin on a patient and they develop peripheral edema ?
What is the mechanism of "Insulin edema" ?
#MedTwitter #MedStudentTwitter
2/8
This condition was initially reported by Aaron Leifer, M.D. in 1928 in a 41-year-old male patient started on an insulin regimen which was published in JAMA.

Leifer A. A CASE OF INSULIN EDEMA. JAMA. 1928;90(8):610–611. doi:10.1001/jama.1928.92690350001012
3/8
The severity of edema is usually mild, involving the limbs, sparing the torso and face.
Resolution is usually seen after one to two weeks of conservative treatment with fluid and salt restriction and may or may not involve the use of diuretics
grepmed.com/images/6334/dr…
Read 8 tweets
Apr 16, 2022
1/17
“The skin truly can be a mirror of what’s going on inside the body “
During a #CPSbootcamp conversation we started discussing mosquito bites. How they can be a signal to internal disease ? Let's explore @deboracloureiro @KirtanPatolia @CPSolvers @seymss15
#MedTwitter
2/17
Mosquito saliva-induced type I hypersensitivity induces a strong itch sensation. This is a process of vasodilation + inflammation

First ➡️ immediate wheal and flare reaction develops within 15–30 min➡️ delayed pruritic induration arises within a day or 2 which resolves
3/17
Hypersensitivity to mosquito bites (HMB):

HMB or severe mosquito bite allergy (SMBA) is a cutaneous form of chronic active Epstein–Barr virus disease (CAEBV).

HMB belongs to a category of Epstein–Barr virus (EBV)-associated NK cell lymphoproliferative disorders (LPD). https://www.sciencedirect.com/science/article/pii/S132389302
Read 17 tweets
May 20, 2021
1/ 10 The most recognized form of Non-Cardiogenic pulmonary edema(NCPE) is ARDS, however the scope of NCPE is much broader with many causes. One particular cause of NCPE we encountered was due to opoid use which is explored in this #medtweetorial
#MedTwitter #MedStudentTwitter
2/10 The onset of noncardiogenic pulmonary edema after opioid overdose was first described by Osler
during an autopsy in 1880

Osler W. Oedema of the left lung — morphia poisoning: Montreal General Hospital Reports Clinical and Pathological. Montreal: Dawson Bros., 1880:291.
3/10 Its presentation and clinical course was not appreciated until the 1950s-60s.
-mechanism is known to involve ⬆️ alveolar capillary permeability
-Opioid-related NCPE presents as :
dyspnea +/- pink, frothy pulmonary secretions
+ hypoxia
Other criteria is detailed below:
Read 10 tweets
Feb 23, 2021
1/ Is bandemia with a normal WBC count concerning for a lethal infection?
It's a very interesting concept which I've faced and will explore below :
#MedTwitter #MedStudentTwitter #FOAMed
2/“Left shift” means that a particular population of cells is “shifted” towards more immature precursors
Josef Arneth (1873-1955) described this left-shift term.

% neutrophils is commonly reported as a "left shift" in the Diff which is incorrect
jamanetwork.com/journals/jama/…
3/Mechanical hematologic counters were used early on last century which perpetuated the term" left shift" with the manual counting of immature neutrophils which were towards the left side of the mature cells on the counter.
Read 11 tweets
Dec 17, 2020
1/ "Don't forget to correct that phosphate so that the it can help the patient recover from acute respiratory failure !" This concept triggered a lot of questions on rounds.
It's worth taking a quick look at this association !
#medtwitter #MedStudentTwitter #FOAMed #phosphate
2/⬇️Phosphate leads to ⬇️red cell 2,3-DPG and a reduction in ATP.
⬇️Phosphate diverts glucose -> 1,3-DPG into the Rapoport-Leubering pathway away from ATP generation towards producing 2,3-DPG so that the oxygen affinity of RBC's does not increase and the tissues receive O2.
3/⬇️Phosphate does also impact RBC survivability with a
⬆️hemolysis, ⬇️in RBC deformability, ⬇️ capillary transit and ⬇️GSH.
Read 11 tweets
Sep 8, 2020
1/ LR has been making the rounds on #MedTwitter recently so I decided to put all of the important points versus NS into an infographic with additional points
@MohitHarshMD
#MedTwitter #MedStudentTwitter #Medtweetorials Image
2/ NS can cause coagulopathy
- NS dilutes clotting factors ➡️ impairing coagulation and hemostasis.
-NS can cause a functional impairment of thrombin and fibrinogen
- ⬆️ disruption of existing clots.
- acidic milieu can also ⬇️ clot formation/stability

pubmed.ncbi.nlm.nih.gov/17414340/
3/ In Traumatology:
NS can lead to:
-compartment syndrome
-dilutional coagulopathy
-hyperchloremic metabolic acidosis
-immune dysfunction

pubmed.ncbi.nlm.nih.gov/16832250/
Read 12 tweets

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