NNR This Month = 73
NNR = Number Needed to Read
You'd have to read 2783 articles to find these 38.
Academic Emergency Medicine
- Albuterol nebs raised lactate 0.8 mmol/L and lowered K by 0.5 meq/L.
- When Internal Medicine beds were turned over faster, the upstream effect on the ED was negligible. Medicine patients had decreased LOS, but only 1/30 ED patients at the Canadian hospital were admitted to Medicine beds, so the overall effect on ED LOS was minimal.
- A RCT comparing DL to VL showed no statistically significant change in first pass success rate with VL.
- Supposedly negative head CTs in 18 patients ultimately diagnosed with SAH were retrospectively reviewed. Fifty percent of those scans were diagnosed as definite or probable SAH upon review by two neuroradiologists. A "negative" head CT could be a false negative and lead to more workup, including LP.
- Apneic oxygenation lead to lower rates of hypoxia during ED intubation. The FELLOW trial below. See prior blog on the FELLOW trial.
- Most firearm injuries occurred in a patient's neighborhood, almost half of them at home. Although mass shootings occur, most firearm violence occurs at home, which informs the public health response to this preventable tragedy.
- Residents signed up for patients more quickly who had simpler chief complaints like "ankle injury" or "wrist pain" and were slower to sign up for complaints like "abdominal pain" or "vaginal bleeding." Whether this reflects a preference for simpler problems or aversion to perceived complaints with greater complexity or for performing a pelvic exam could not be determined on the basis of this study. But I think I know the answer to that question.
Acad Emerg Med. 2016 Feb 9. doi: 10.1111/acem.12937. [Epub ahead of print]
1Department of Emergency Medicine, University of Nevada School of Medicine.
2University Medical Center of Southern Nevada.
To determine if nebulized albuterol causes an increase in the serum lactate level compared to placebo. Secondarily, to confirm that albuterol decreases serum potassium levels compared to placebo in patients with normokalemia.
This was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy adult volunteers were assigned to receive either 10 mg of nebulized albuterol or placebo (nebulized saline) over one hour. Serum lactate was measured prior to treatment and at 30 minutes and 70 minutes after the start of treatment. Serum potassium level was measured prior to treatment and at 70 minutes. The primary outcome was the degree of change in lactate level. The secondary outcome was the degree of change in potassium level.
In the 14 subjects who received albuterol, the average increase in lactate was 0.77 mmol/L [95% CI 0.52 to 1.02 mmol/L], and the average decrease in potassium level was 0.5 mEq/L [95% CI -0.72 to -0.28 mEq/L]. Amongst the subjects who received placebo, the lactate level decreased by 0.15 mmol/L [95% CI -0.39 to 0.09 mmol/L] and there was no change in potassium level at (0.0 mEq/L [95% CI -0.21 to 0.21 mEq/L]). These differences are statistically significant (P < 0.0001 and P = 0.003, respectively).
Nebulized albuterol increases lactate levels and decreases potassium levels in healthy adults. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26857949 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 6. doi: 10.1111/acem.12935. [Epub ahead of print]
1General Internal Medicine University of Alberta.
2Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta.
3Data Integration Measurement and Reporting, Alberta Health Services.
4Department of Pediatrics, University of Alberta.
5Department of Emergency Medicine and School of Public Health, University of Alberta and Emergency Strategic Clinical Network, Alberta Health Services, all in Edmonton, Alberta, Canada.
The General Internal Medicine (GIM) Care Transformation Initiative implemented at 1 of 4 teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the Emergency Department (ED) is unclear.
Controlled before-after study of ED length of stay (LOS) and crowding metrics for the intervention site (n=108,951 visits) compared to the three other teaching hospitals (controls, n=300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics.
The GIM Care Transformation was associated with an additional 2.8 hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3 hour decline (from 30.6 hours to 21.3 hours) seen in the 3 control EDs for GIM patients who were hospitalized (p<0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p<0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p<0.001) at the intervention hospital pre vs. post (p=0.04 for the 15 minute additional reduction, p<0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences.
Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26850577 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 6. doi: 10.1111/acem.12933. [Epub ahead of print]
1Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN, USA.
2Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN, USA.
Direct laryngoscopy (DL) has long been the most common approach for emergency endotracheal intubation, though the use of video laryngoscopy (VL) is becoming more widespread. Current observational data suggest that VL has higher first pass success, though randomized trials are lacking.
To compare first pass success in patients undergoing emergency intubation intubated with DL or VL using a C-MAC device.
This was an open-label, prospective, randomized, controlled trial in an academic Emergency Department of patients undergoing emergency intubation with a plan of DL for the first attempt. Patients were randomly assigned in a 1:1 ratio to either DL or VL using a C-MAC device for the first intubation attempt. The primary outcome was first pass success. Secondary outcomes included time to intubation, development of aspiration pneumonia, and hospital length of stay. The study was registered at Clinicaltrials. gov, number NCT01710891.
198 patients were enrolled and intubated with either DL (n=95) or VL (n=103). First attempt success was 86% and 92% for the DL and VL groups, respectively (difference 6%, 95% CI -14.5% to 3%, p=0.18). Time to intubation, rates of aspiration pneumonia, and hospital length of stay were not different between the two groups.
In patients undergoing emergency intubation in whom DL was planned for the first attempt, we did not detect a difference between video or direct laryngoscopy using the C-MAC device in first pass success, duration of intubation attempt, aspiration pneumonia, or hospital length of stay. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26850232 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 26. doi: 10.1111/acem.12941. [Epub ahead of print]
1Kaiser Permanente, Departments of Emergency Medicine and Critical Care, Oakland, California.
2Kaiser Permanente, Department of Radiology, Oakland, California.
3Kaiser Permanente, Department of Radiology, Santa Clara, California.
4New York University School of Medicine, Department of Emergency Medicine, New York, NY.
5Kaiser Permanente, Department of Emergency Medicine San Leandro, California.
6Kaiser Permanente, Department of Emergency Medicine, Roseville, California.
7Kaiser Permanente, Department of Emergency Medicine, San Rafael, California.
Prior studies examining the sensitivity of cranial computed tomography (CT) for the detection of subarachnoid hemorrhage (SAH) have used the final radiology report as the reference standard. However, optimal sensitivity may have been underestimated due to misinterpretation of reportedly normal cranial CTs. This study aims to estimate the incidence of missed CT evidence of SAH among a cohort of patients with aneurysmal SAH (aSAH).
We performed a retrospective chart review of emergency department (ED) encounters within an integrated health delivery system between January 2007 and June 2013 to identify patients diagnosed with aSAH. All initial non-contrast CTs from aSAH cases diagnosed by lumbar puncture (LP) and angiography following a reportedly normal non-contrast cranial CT (CT-negative aSAH) were then reviewed in a blinded, independent fashion by two board-certified neuroradiologists to assess for missed evidence of SAH. Reviewers rated the CT studies as having either definite evidence of SAH, probable evidence of SAH, or no evidence of SAH. Control patients who underwent a negative evaluation for aSAH based on cranial CT and LP results were also included at random in the imaging review cohort.
A total of 452 cases of aSAH were identified; 18 (4%) were cases of CT-negative aSAH. Of these, 7 (39%) underwent cranial CT within six hours of headache onset, and 2 (11%) had their initial CTs formally interpreted by board-certified neuroradiologists. Blinded independent CT review revealed concordant agreement for either definite or probable evidence of SAH in 9 out of 18 (50%) cases overall, and in 5 of the 7 (71%) CTs performed within six hours of headache onset. Inter-rater agreement was 83% for definite SAH and 72% for either probable or definite SAH.
CT evidence of SAH was frequently present but unrecognized according to the final radiology report in cases of presumed CT-negative aSAH. This finding may help explain some of the discordance between prior studies examining the sensitivity of cranial CT for SAH. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26918885 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 2. doi: 10.1111/acem.12931. [Epub ahead of print]
1Emergency Medicine, Department of Emergency Medicine, University of Arizona.
2Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy.
3University of Arizona College of Medicine.
To determine the effect of apneic oxygenation (AP OX) on first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).
Continuous quality improvement (CQI) data were prospectively collected on all patients intubated in an academic ED from July 1, 2013 to June 30, 2015. During this period the use of AP OX was introduced and encouraged for all patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data form which included information on patient, operator and intubation characteristics. Adult patients 18 years of age or greater who underwent RSI in the ED by emergency medicine residents were included in the analysis. The primary outcome was FPS-H, which was defined as successful tracheal intubation on a single laryngoscope insertion without oxygen saturation falling below 90%. A multivariate logistic regression analysis was performed to determine the effect of AP OX on FPS-H.
During the two-year study period, 635 patients met inclusion criteria. Of these, 380 (59.8%) had AP OX utilized and 255 (40.2%) had NO AP OX utilized. In the AP OX cohort the FPS-H was 312/380 (82.1%) and in the NO AP OX cohort the FPS-H was 176/255 (69.0%) (difference 13.1%; 95% CI 6.2% to 19.9%). In the multivariate logistic regression analysis, the use of AP OX was associated with an increased odds of FPS-H (adjusted OR 2.2; 95% CI: 1.5 to 3.3).
The use of AP OX during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of AP OX has the potential to increase the safety of RSI in the ED by reducing the number of attempts and incidence of hypoxemia. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26836712 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 2. doi: 10.1111/acem.12930. [Epub ahead of print]
1Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon.
2Department of Biostatistics, University of Washington, Seattle, Washington.
3Department of Surgery, University of Washington, Seattle, Washington.
4Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
5Department of Surgery, Oregon Health & Science University, Portland, Oregon.
6St. Michael's Hospital, Toronto, Ontario.
7Department of Emergency Medicine, University of Pittsburgh Medical Center Pittsburgh, PA.
8University of Texas Southwestern Medical Center, Dallas, TX.
Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and non-violent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering and outcomes.
This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale (GCS) score ≤ 8, injured by one of 4 primary injury mechanisms (firearm, stabbing, assault and MVC) who were transported by EMS to a Level I or II trauma center in 10 regions of the U.S. and Canada from January 1, 2010 through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes and spatial clustering.
There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%) and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included: 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters.
Severe firearm events tend to occur within the patient's own neighborhood, often at home and generally outside of specific geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
PMID: 26836571 [PubMed - as supplied by publisher]
Acad Emerg Med. 2016 Feb 13. doi: 10.1111/acem.12895. [Epub ahead of print]
1BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI.
2Wisconsin School of Business, the University of Wisconsin-Madison, Madison, WI.
We aimed to evaluate the association between patient chief complaint and the time interval between patient rooming and resident physician self-assignment ("pickup time"). We hypothesized that significant variation in pickup time would exist based on chief complaint, thereby uncovering resident preferences in patient presentations.
A retrospective medical record review was performed on consecutive patients at a single, academic, university-based emergency department with over 50,000 visits per year. All patients who presented from August 1, 2012, to July 31, 2013, and were initially seen by a resident were included in the analysis. Patients were excluded if not seen primarily by a resident or if registered with a chief complaint associated with trauma team activation. Data were abstracted from the electronic health record (EHR). The outcome measured was "pickup time," defined as the time interval between room assignment and resident self-assignment. We examined all complaints with >100 visits, with the remaining complaints included in the model in an "other" category. A proportional hazards model was created to control for the following prespecified demographic and clinical factors: age, race, sex, arrival mode, admission vital signs, Emergency Severity Index code, waiting room time before rooming, and waiting room census at time of rooming.
Of the 30,382 patients eligible for the study, the median time to pickup was 6 minutes (interquartile range = 2-15 minutes). After controlling for the above factors, we found systematic and significant variation in the pickup time by chief complaint, with the longest times for patients with complaints of abdominal problems, numbness/tingling, and vaginal bleeding and shortest times for patients with ankle injury, allergic reaction, and wrist injury.
A consistent variation in resident pickup time exists for common chief complaints. We suspect that this reflects residents preferentially choosing patients with simpler workups and less perceived diagnostic ambiguity. This work introduces pickup time as a metric that may be useful in the future to uncover and address potential physician bias. Further work is necessary to establish whether practice patterns in this study are carried beyond residency and persist among attendings in the community and how these patterns are shaped by the information presented via the EHR.
© 2016 by the Society for Academic Emergency Medicine.
PMID: 26874338 [PubMed - as supplied by publisher]
American Journal of Emergency Medicine
- Active elbow ROM - full extension, flexion to 90°, full pronation and supination - had 99% sensitivity and NPV for elbow fracture. Most patients were adults, with few kids enrolled.
- ST elevation in the inferior leads with ST depression in avL is very sensitive for inferior STEMI (154 of 154 patients with STEMI). Whereas patients with pericarditis in this study had inferior lead ST elevation but no ST depression in avL (49 of 49 patients with pericarditis).
Am J Emerg Med. 2016 Feb;34(2):235-9. doi: 10.1016/j.ajem.2015.10.031. Epub 2015 Oct 24.
1The Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA. Electronic address: email@example.com.
2The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA.
3Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA.
4Department of Emergency Medicine, University of South Alabama Medical Center, Mobile, AL.
Acute elbow injuries are common in the acute care setting. A previous study observed that limited active range of motion (ROM) was highly sensitive for radiographic injuries after blunt trauma. Our aim was to validate these findings in patients ≥5 years old with an acute (<24 hours) nonpenetrating elbow injury.
This prospective study included a convenience sample of patients undergoing plain radiographs of an injured elbow in 3 emergency departments. Before imaging, treating clinicians completed a standardized data collection sheet including mechanism of injury and 4-way ROM findings (full extension, flexion to 90°, full pronation and supination). Radiographic interpretation by a staff radiologist was used to ascertain the presence of fracture or joint effusion.
The median age of the 251 patients was 24 years. Ninety-two patients (36.7%) had active 4-way ROM, and 159 patients (63.3%) demonstrated limited ROM. Negative radiographs were present in 152 patients (60.6%), whereas 99 patients (39.4%) had abnormal radiographs: 75 with explicit fractures and 24 with only joint effusions. The 4-way ROM elbow test had a sensitivity of 0.99 (95% confidence interval [CI], 0.94-1.00), specificity of 0.60 (95% CI, 0.52-0.68), positive predictive value of 0.62 (95% CI, 0.54-0.69), and negative predictive value of 0.99 (95% CI, 0.94-1.00).
Active 4-way ROM test is 99% sensitive for all radiographic injures following blunt elbow trauma and 100% sensitive for injuries requiring surgical intervention. Caution should be used in relying on this test in the pediatric population until it is validated in a larger cohort.
Copyright © 2015 Elsevier Inc. All rights reserved.
PMID: 26597495 [PubMed - in process]
Am J Emerg Med. 2016 Feb;34(2):149-54. doi: 10.1016/j.ajem.2015.09.035. Epub 2015 Oct 3.
1Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN. Electronic address: Johanna.firstname.lastname@example.org.
2Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
3Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN. Electronic address: email@example.com.
4Department of Cardiology, Defense Central Hospital Gomez Ulla, University of Alcala, Madrid, Spain. Electronic address: firstname.lastname@example.org.
5Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN. Electronic address: email@example.com.
ST-segment elevation (STE) due to inferior STE myocardial infarction (STEMI) may be misdiagnosed as pericarditis. Conversely, this less life-threatening etiology of ST elevation may be confused for inferior STEMI. We sought to determine if the presence of any ST-segment depression in lead aVL would differentiate inferior STEMI from pericarditis.
Retrospective study of 3 populations. Cohort 1 included patients coded as inferior STEMI, cohort 2 included patients with a discharge diagnosis of pericarditis who presented with chest pain and at least 0.5 mm of ST elevation in at least 1 inferior lead. We analyzed the presenting electrocardiogram in both populations, with careful assessment of leads II, III, aVF, and aVL. In addition, we retrospectively studied a third cohort of patients with subtle inferior STEMI (<1-mm STE with occluded artery on catheterization) and assessed the sensitivity of ST depression in lead aVL for this group.
Of 154 inferior STEMI patients, 154 had some amount of ST depression in lead aVL (100%; confidence interval, 98%-100%). Of the 49 electrocardiograms in the pericarditis group, all 49 had some inferior STE but none had any ST-segment depression in lead aVL (specificity, 100%; confidence interval, 91%-100%). In the third cohort, there were 272 inferior MIs with coronary occlusion, of which 54 were "subtle." Of these, 49 had some ST depression in lead aVL.
When there is inferior ST-segment elevation, the presence of any ST depression in lead aVL is highly sensitive for coronary occlusion in inferior myocardial infarction and very specific for differentiating inferior myocardial infarction from pericarditis.
Copyright © 2015 Elsevier Inc. All rights reserved.
PMID: 26542793 [PubMed - in process]
American Journal of Respiratory and Critical Care Medicine
The FELLOW trial about apneic oxygenation not being helpful in reducing hypoxia in ICU patients requiring intubation was officially published this month. See the discussion on the early release version last month.
Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80. doi: 10.1164/rccm.201507-1294OC.
Semler MW1, Janz DR2, Lentz RJ1, Matthews DT1, Norman BC1, Assad TR1, Keriwala RD1, Ferrell BA1, Noto MJ1, McKown AC1, Kocurek EG1, Warren MA1, Huerta LE1, Rice TW1; FELLOW Investigators and the Pragmatic Critical Care Research Group.
11 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; and.
22 Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana.
Hypoxemia is common during endotracheal intubation of critically ill patients and may predispose to cardiac arrest and death. Administration of supplemental oxygen during laryngoscopy (apneic oxygenation) may prevent hypoxemia.
To determine if apneic oxygenation increases the lowest arterial oxygen saturation experienced by patients undergoing endotracheal intubation in the intensive care unit.
This was a randomized, open-label, pragmatic trial in which 150 adults undergoing endotracheal intubation in a medical intensive care unit were randomized to receive 15 L/min of 100% oxygen via high-flow nasal cannula during laryngoscopy (apneic oxygenation) or no supplemental oxygen during laryngoscopy (usual care). The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after completion of endotracheal intubation.
MEASUREMENTS AND MAIN RESULTS:
Median lowest arterial oxygen saturation was 92% with apneic oxygenation versus 90% with usual care (95% confidence interval for the difference, -1.6 to 7.4%; P = 0.16). There was no difference between apneic oxygenation and usual care in incidence of oxygen saturation less than 90% (44.7 vs. 47.2%; P = 0.87), oxygen saturation less than 80% (15.8 vs. 25.0%; P = 0.22), or decrease in oxygen saturation greater than 3% (53.9 vs. 55.6%; P = 0.87). Duration of mechanical ventilation, intensive care unit length of stay, and in-hospital mortality were similar between study groups.
Apneic oxygenation does not seem to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared with usual care. These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. Clinical trial registered with www.clinicaltrials.gov (NCT 02051816).
PMID: 26426458 [PubMed - in process]
Anesthesia and Analgesia
Raising the back and elevating the patient's head while anesthesiologists performed emergent intubations on hospitalized patients (outside the OR) reduced the odds of airway complications, namely difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration (odds ratio 0.47).
Anesth Analg. 2016 Feb 10. [Epub ahead of print]
1From the *Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington; †Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and ‡Division of Emergency Medicine, University of Washington, Seattle, Washington.
Based on the data from elective surgical patients, positioning patients in a back-up head-elevated position for preoxygenation and tracheal intubation can improve patient safety. However, data specific to the emergent setting are lacking. We hypothesized that back-up head-elevated positioning would be associated with a decrease in complications related to tracheal intubation in the emergency room environment.
This retrospective study was approved by the University of Washington Human Subjects Division (Seattle, WA). Eligible patients included all adults undergoing emergent tracheal intubation outside of the operating room by the anesthesiology-based airway service at 2 university-affiliated teaching hospitals. All intubations were through direct laryngoscopy for an indication other than full cardiopulmonary arrest. Patient characteristics and details of the intubation procedure were derived from the medical record. The primary study endpoint was the occurrence of a composite of any intubation-related complication: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. Multivariable logistic regression was used to estimate the odds of the primary endpoint in the supine versus back-up head-elevated positions with adjustment for a priori-defined potential confounders (body mass index and a difficult intubation prediction score [Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score]).
Five hundred twenty-eight patients were analyzed. Overall, at least 1 intubation-related complication occurred in 76 of 336 (22.6%) patients managed in the supine position compared with 18 of 192 (9.3%) patients managed in the back-up head-elevated position. After adjusting for body mass index and the Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score, the odds of encountering the primary endpoint during an emergency tracheal intubation in a back-up head-elevated position was 0.47 (95% confidence interval, 0.26-0.83; P = 0.01).
Placing patients in a back-up head-elevated position, compared with supine position, during emergency tracheal intubation was associated with a reduced odds of airway-related complications.
PMID: 26866753 [PubMed - as supplied by publisher]
Annals of Emergency Medicine
- After you have used all the droperidol in the department (some patients got 10-30mg), is ketamine a safe alternative? Yes, although they required 4-5mg/kg, yes 200-300mg IM! Of 49 patients, 2 vomited and 1 had transient desaturation to 90%, improved with O2.
- The same doctors got consistently worse patient satisfaction scores when they worked in the ED as opposed to the hospital's urgent care. This goes to show that patient satisfaction scores must be taken with a grain of salt. There is much beyond our control that factors into a patient's opinion of the doctor, and the environment certainly affects their responses.
- An age adjusted D-dimer is safe to use. See the blog written when this article was first released electronically.
Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01562-0. doi: 10.1016/j.annemergmed.2015.11.028. [Epub ahead of print]
1Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia; Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia. Electronic address: firstname.lastname@example.org.
2Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia.
3Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia; Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia; Emergency Department, Calvary Mater Newcastle, Newcastle, Australia.
4Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia; Emergency Department, Princess Alexandra Hospital, and School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
We investigate the effectiveness and safety of ketamine to sedate patients with severe acute behavioral disturbance who have failed previous attempts at sedation.
This was a prospective study of patients given ketamine for sedation who had failed previous sedation attempts. Patients with severe acute behavioral disturbance requiring parenteral sedation were treated with a standardized sedation protocol including droperidol. Demographics, drug dose, observations, and adverse effects were recorded. The primary outcome was the number of patients who failed to sedate within 120 minutes of ketamine administration or requiring further sedation within 1 hour.
Forty-nine patients from 2 hospitals were administered rescue ketamine during 27 months; median age was 37 years (range 20-82 years); 28 were men. Police were involved with 20 patients. Previous sedation included droperidol (10 mg; 1), droperidol (10+10 mg; 33), droperidol (10+10+5 mg; 1), droperidol (10+10+10 mg; 11), and combinations of droperidol and benzodiazepines (2) and midazolam alone (1). The median dose of ketamine was 300 mg (range 50 to 500 mg). Five patients (10%; 95% confidence interval 4% to 23%) were not sedated within 120 minutes or required additional sedation within 1 hour. Four of 5 patients received 200 mg or less. Median time to sedation postketamine was 20 minutes (interquartile range 10 to 30 minutes; 2 to 500 minutes). Three patients (6%) had adverse effects, 2 had vomiting, and a third had a transient oxygen desaturation to 90% after ketamine that responded to oxygen.
Ketamine appeared effective and did not cause obvious harm in this small sample and is a potential option for patients who have failed previous attempts at sedation. A dose of 4 to 5 mg/kg is suggested, and doses less than 200 mg are associated with treatment failure.
Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 26899459 [PubMed - as supplied by publisher]
Ann Emerg Med. 2016 Feb 10. pii: S0196-0644(15)01611-X. doi: 10.1016/j.annemergmed.2015.12.021. [Epub ahead of print]
1Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ; Department of Emergency Medicine, Mercy Fitzgerald Hospital, Darby, PA.
2Cooper University Hospital, Camden, NJ.
3Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ.
4Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ. Electronic address: email@example.com.
We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated.
We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician courtesy.
Seventeen physicians met inclusion criteria. For all 17 physicians, the point estimate for the mean urgent care courtesy score was higher than the point estimate for the mean ED courtesy score. The mean difference in courtesy scores between urgent care and the ED was 0.35 (95% confidence interval 0.22 to 0.49). ED scores were also consistently lower than urgent care scores for keeping patients informed about their treatment, concern for patient comfort, listening ability, and overall care rating.
Although these results are limited by small sample size, we found that physicians consistently received lower satisfaction ratings from ED patients than from urgent care patients. This challenges the validity of using satisfaction scores to compare providers in different practice settings.
Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 26875063 [PubMed - as supplied by publisher]
Ann Emerg Med. 2016 Feb;67(2):249-57. doi: 10.1016/j.annemergmed.2015.07.026. Epub 2015 Aug 29.
1Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Emergency Medicine, Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA. Electronic address: firstname.lastname@example.org.
2Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA; Kaiser Permanente Division of Research, Oakland, CA.
3Department of Family Medicine, Anaheim Medical Center, Kaiser Permanente Southern California, Anaheim, CA.
4Department of Internal Medicine, Anaheim Medical Center, Kaiser Permanente Southern California, Anaheim, CA.
5Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism.
This was a retrospective study of ED encounters for suspected pulmonary embolism from 2008 to 2013. We used structured data to calculate the sensitivity, specificity, negative predictive value, and positive predictive value of different D-dimer thresholds. We describe the incidence of pulmonary embolism, the proportion of patients receiving imaging concordant with D-dimer levels, and the number of "missed" pulmonary embolisms. These findings were used to estimate patient outcomes based on different D-dimer thresholds.
Among 31,094 encounters for suspected pulmonary embolism, there were 507 pulmonary embolism diagnoses. The age-adjusted D-dimer threshold was more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL; 11,999 imaging studies identified 507 pulmonary embolisms (4.2%); of these, 1,323 (10.6%) were performed with a D-dimer result below the standard threshold. Among patient encounters without imaging, 17.6% had D-dimer values above the threshold, including 5 missed pulmonary embolisms. Among patients who received imaging, 10.6% had a negative D-dimer result. Applying an age-adjusted D-dimer threshold to our sample would avert 2,924 low-value imaging tests while resulting in 26 additional cases of missed pulmonary embolism.
An age-adjusted D-dimer limit has the potential to reduce chest imaging among older ED patients and is more accurate than a standard threshold of 500 ng/dL. Our findings support the adoption of an age-adjusted D-dimer cutoff in community EDs.
Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 26320520 [PubMed - in process]
Annals of Internal Medicine
This RCT comparing prednisone and indomethacin showed both are equally effective in reducing pain from acute gout.
Ann Intern Med. 2016 Feb 23. doi: 10.7326/M14-2070. [Epub ahead of print]
Two recent double-blind randomized, controlled trials (RCTs) showed that oral steroids and nonsteroidal anti-inflammatory drugs have similar analgesic effectiveness for management of gout, but the trials had small sample sizes and other methodological limitations.
To compare the effectiveness and safety of oral prednisolone versus oral indomethacin in patients presenting to emergency departments (EDs) with acute gout.
Multicenter, double-blind, randomized equivalence trial. Patients were randomly assigned (1:1 ratio) to receive either indomethacin or prednisolone. (ISRCTN registry number: ISRCTN45724113).
Four EDs in Hong Kong.
416 patients aged 18 years or older.
Analgesic effectiveness was defined as changes in pain (at rest or with activity) greater than 13 mm on a 100-mm visual analogue scale. Outcomes were measured during the first 2 hours in the ED and from days 1 to 14.
376 patients completed the study. Equivalent and clinically significant within-group reductions in mean pain score were observed with indomethacin and prednisolone in the ED (approximately 10 mm [rest] and 20 mm [activity]) and from days 1 to 14 (approximately 25 mm [rest] and 45 mm [activity]). No major adverse events occurred during the study. During the ED phase, patients in the indomethacin group had more minor adverse events than those in the prednisolone group (19% vs. 6%; P < 0.001). During days 1 to 14, 37% of patients in each group had minor adverse events.
Diagnosis of gout was usually based on clinical criteria rather than examination of joint fluid.
Oral prednisolone and indomethacin had similar analgesic effectiveness among patients with acute gout. Prednisolone is an effective and safe first-line option for treatment of acute gout.
Primary Funding Source:
Health and Health Services Research Grant Committee of the Hong Kong Government.
PMID: 26903390 [PubMed - as supplied by publisher]
British Medical Journal
There was no increased risk of arrhythmia in fluoroquinolone users compared to baseline penicillin users in this large study. The most often used fluoroquinolone was ciprofloxacin but there was no association with other fluoroquinolones either.
BMJ. 2016 Feb 26;352:i843. doi: 10.1136/bmj.i843.
1Lund University, Department of Clinical Sciences Lund, Section for Infection Medicine, Lund, Sweden email@example.com.
2Department of Epidemiology Research, Statens Serum Institut, 2300 Copenhagen S, Denmark.
To evaluate if oral fluoroquinolone use is associated with an increased risk of serious arrhythmia.
Bi-national cohort study, linking register data on filled prescriptions, cases of serious arrhythmia, and patient characteristics.
Denmark, 1997-2011; Sweden, 2006-13.
The study cohort was derived from a source population of all Danish and Swedish adults, aged 40 to 79 years. 909 656 courses of fluoroquinolone use (ciprofloxacin 82.6%, norfloxacin 12.1%, ofloxacin 3.2%, moxifloxacin 1.2%, and other fluoroquinolones 0.9%) and 909 656 courses of penicillin V use, matched 1:1 on propensity score, were included.
MAIN OUTCOME MEASURE:
The main outcome was risk of serious arrhythmia (fatal and non-fatal), comparing courses of fluoroquinolone use with courses of penicillin V use (an antibiotic with no pro-arrhythmic effect). The risk period of interest was current use, defined as days 0-7 of treatment. Subgroup analyses were conducted according to country, sex, age, underlying cardiovascular disease, concomitant use of drugs known to increase the risk of torsades de pointes, fluoroquinolone type, and levels of arrhythmia risk score.
144 cases of serious arrhythmia occurred during follow-up, 66 among current fluoroquinolone users (incidence rate 3.4 per 1000 person years) and 78 among current penicillin users (4.0 per 1000 person years); comparing oral fluoroquinolone treatment with penicillin V, the rate ratio was 0.85 (95% confidence interval 0.61 to 1.18). Compared with penicillin V, the absolute risk difference was -13 (95% confidence interval -35 to 16) cases of serious arrhythmia per 1 000 000 courses of fluoroquinolones. The risk of serious arrhythmia was not statistically significantly increased in any of the subgroups, including analyses by fluoroquinolone type.
Contrary to previous reports, oral fluoroquinolone treatment was not associated with an increased risk of serious arrhythmia in the general adult populations of Denmark and Sweden. Given the statistical power of the study, even small increases in relative and absolute risk could be ruled out. Since ciprofloxacin was the most commonly used fluoroquinolone in our study, we cannot exclude that intraclass differences influence the risk of serious arrhythmia associated with other less frequently used fluoroquinolones.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID: 26920666 [PubMed - as supplied by publisher]
How long should prehospital CPR be continued? This Japanese study found that CPR should be performed for at least 40 minutes before termination.
Circulation. 2016 Feb 26. pii: CIRCULATIONAHA.115.018788. [Epub ahead of print]
1Nihon University Hospital, Tokyo, Japan firstname.lastname@example.org.
2Shizuoka General Hospital, Shizuoka, Japan.
3National Center of Neurology and Psychiatry, Tokyo, Japan.
4Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
5Kawasaki Saiwai Hospital, Kawasaki, Japan.
6Sakakibara Heart Institute, Tokyo, Japan.
7Kokura Memorial Hospital, Kitakyushu, Japan.
8Nihon University Hospital, Tokyo, Japan.
9Kyoto University, Kyoto, Japan.
10Fukuoka University of School of Medicine, Fukuoka, Japan.
-During out-of-hospital cardiac arrest (OHCA), it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved.
METHODS AND RESULTS:
-Between 2005 and 2012, we enrolled 282,183 adult patients with bystander-witnessed OHCA from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation (ROSC) in cases achieving prehospital ROSC or from call receipt to hospital arrival in cases not achieving prehospital ROSC. In each of four groups stratified by initial cardiac arrest rhythm (shockable versus non-shockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary endpoint, favorable 30-day neurological outcome after OHCA. Prehospital resuscitation duration to achieve prehospital ROSC ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different between the four groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (non-shockable/bystander resuscitation group) [P<0.001], minimum prehospital resuscitation duration did not differ widely between the four groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the non-shockable/bystander resuscitation group and 45 minutes in the non-shockable/no bystander resuscitation group).
-Based on time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed OHCA.
CLINICAL TRIAL REGISTRATION INFORMATION:
-www.umin.ac.jp/ctr/. Identifier: 000009918.
PMID: 26920493 [PubMed - as supplied by publisher]
Emergency Medicine Journal
The longer a shoulder is dislocated, the lower the chance of successful reduction. For every ten minutes from the time of injury, the odds of unsuccessful reduction increases 7%.
Emerg Med J. 2016 Feb;33(2):130-3. doi: 10.1136/emermed-2015-204746. Epub 2015 Jun 25.
1Faculty of Medicine, University College Cork, Cork, Ireland Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada.
2Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada Discipline of Emergency Medicine, Memorial University, Saint John, New Brunswick, Canada New Brunswick Trauma Program, Saint John Regional Hospital, Saint John, New Brunswick, Canada.
3Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada Discipline of Emergency Medicine, Memorial University, Saint John, New Brunswick, Canada.
4Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada.
5Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada New Brunswick Trauma Program, Saint John Regional Hospital, Saint John, New Brunswick, Canada.
Little is understood about the relationship between delay to treatment and initial reduction success for anterior shoulder dislocation. Our study examines whether delays to initial treatment, from injury and hospital presentation, are associated with higher reduction failure rates for anterior shoulder dislocation.
A retrospective database and chart review was performed for patients undergoing intravenous sedation for attempted reduction of anterior shoulder dislocation in the emergency department (ED). Stepwise regression analysis was performed to identify predictors of reduction failure. Key variables analysed were the duration of the wait in the ED, the interval between the time of injury and first intervention and the interval from time of injury to arrival at the ED. Possible confounding variables analysed included age, gender, dose of sedative agent, qualifications of the reducing physician and whether the dislocated shoulder was recurrent.
The duration of the intervals from injury to first reduction attempt and from arrival at the ED to first reduction attempt were both independent predictors of a higher reduction failure rate (OR=1.07, 95% CI 1.02 to 1.13; OR=1.19, 95% CI 1.05 to 1.34). Every interval of 10 min increased the odds of a failed reduction attempt by 7% and 19%, respectively. Overall, shoulder reduction was successful during the initial sedation event in 97 cases (92%) and unsuccessful in nine cases (8%).
Delays to first reduction attempt either from the time of injury or within the ED are associated with a lower reduction success rate for anterior shoulder dislocations.
PMID: 26113487 [PubMed - in process]
Intensive Care Medicine
- Aiming for a goal MAP of 60-65 vs 75-80 in vasodilatory shock patients was possible, which was the primary outcome of this study. Overall, the secondary outcome of mortality was no different, except is the subgroup of patients over 75 years.
- Patients with lactate >10 or poor lactate clearance (33%) in 12 hours had very high mortality, 78% and 96% respectively.
Intensive Care Med. 2016 Feb 18. [Epub ahead of print]
Lamontagne F1,2,3, Meade MO4,5, Hébert PC6, Asfar P7, Lauzier F8,9,10, Seely AJ11,12, Day AG13, Mehta S14, Muscedere J15, Bagshaw SM16, Ferguson ND14, Cook DJ4,5, Kanji S12, Turgeon AF9,10, Herridge MS14, Subramanian S17, Lacroix J18, Adhikari NK14,19, Scales DC14,19, Fox-Robichaud A4, Skrobik Y20, Whitlock RP21,22, Green RS23, Koo KK24, Tanguay T25, Magder S20, Heyland DK13; Canadian Critical Care Trials Group..
1Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. email@example.com.
2Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada. firstname.lastname@example.org.
3Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada. email@example.com.
4Department of Medicine, McMaster University, Hamilton, ON, Canada.
5Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
6Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada.
7Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France.
8Department of Medicine, Université Laval, Quebec, QC, Canada.
9Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada.
10CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, Quebec, QC, Canada.
11Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada.
12Ottawa Hospital Research Institute, Ottawa, ON, Canada.
13Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
14Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
15Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
16Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
17Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA.
18Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada.
19Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
20McGill University, Montreal, QC, Canada.
21Department of Surgery, McMaster University, Hamilton, ON, Canada.
22Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
23Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
24Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA.
25Canadian Association of Critical Care Nurses, London, ON, Canada.
In shock, hypotension may contribute to inadequate oxygen delivery, organ failure and death. We conducted the Optimal Vasopressor Titration (OVATION) pilot trial to inform the design of a larger trial examining the effect of lower versus higher mean arterial pressure (MAP) targets for vasopressor therapy in shock.
We randomly assigned critically ill patients who were presumed to suffer from vasodilatory shock regardless of admission diagnosis to a lower (60-65 mmHg) versus a higher (75-80 mmHg) MAP target. The primary objective was to measure the separation in MAP between groups. We also recorded days with protocol deviations, enrolment rate, cardiac arrhythmias and mortality for prespecified subgroups.
A total of 118 patients were enrolled from 11 centres (2.3 patients/site/month of screening). The between-group separation in MAP was 9 mmHg (95 % CI 7-11). In the lower and higher MAP groups, we observed deviations on 12 versus 8 % of all days on vasopressors (p = 0.059). Risks of cardiac arrhythmias (20 versus 36 %, p = 0.07) and hospital mortality (30 versus 33 %, p = 0.84) were not different between lower and higher MAP arms. Among patients aged 75 years or older, a lower MAP target was associated with reduced hospital mortality (13 versus 60 %, p = 0.03) but not in younger patients.
This pilot study supports the feasibility of a large trial comparing lower versus higher MAP targets for shock. Further research may help delineate the reasons for vasopressor dosing in excess of prescribed targets and how individual patient characteristics modify the response to vasopressor therapy.
PMID: 26891677 [PubMed - as supplied by publisher]
Intensive Care Med. 2016 Feb;42(2):202-10. doi: 10.1007/s00134-015-4127-0. Epub 2015 Nov 10.
1Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. firstname.lastname@example.org.
2Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
3Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
Hyperlactatemia may occur for a variety of reasons and is a predictor of poor clinical outcome. However, only limited data are available on the underlying causes of hyperlactatemia and the mortality rates associated with severe hyperlactatemia in critically ill patients. We therefore aimed to evaluate the etiology of severe hyperlactatemia (defined as a lactate level >10 mmol/L) in a large cohort of unselected ICU patients. We also aimed to evaluate the association between severe hyperlactatemia and lactate clearance with ICU mortality.
In this retrospective, observational study at an University hospital department with 11 ICUs during the study period between 1 April 2011 and 28 February 2013, we screened 14,040 ICU patients for severe hyperlactatemia (lactate >10 mmol/L).
Overall mortality in the 14,040 ICU patients was 9.8 %. Of these, 400 patients had severe hyperlactatemia and ICU mortality in this group was 78.2 %. Hyperlactatemia was associated with death in the ICU [odds ratio 1.35 (95 % CI 1.23; 1.49; p < 0.001)]. The main etiology for severe hyperlactatemia was sepsis (34.0 %), followed by cardiogenic shock (19.3 %), and cardiopulmonary resuscitation (13.8 %). Patients developing severe hyperlactatemia >24 h of ICU treatment had a significantly higher ICU mortality (89.1 %, 155 of 174 patients) than patients developing severe hyperlactatemia ≤24 h of ICU treatment (69.9 %, 158 of 226 patients; p < 0.0001). Lactate clearance after 12 h showed a receiver-operating-characteristics area under the curve (ROC-AUC) value of 0.91 to predict ICU mortality (cut-off showing highest sensitivity and specifity was a 12 h lactate clearance of 32.8 %, Youden Index 0.72). In 268 patients having a 12-h lactate clearance <32.8 % ICU mortality was 96.6 %.
Severe hyperlactatemia (>10 mmol/L) is associated with extremely high ICU mortality especially when there is no marked lactate clearance within 12 h. In such situations, the benefit of continued ICU therapy should be evaluated.
PMID: 26556617 [PubMed - in process]
Journal of the American College of Cardiology
Sometimes we are called on to start a new antihypertensive on our ED patients. Beta blockers and HCTZ are a mainstay. In this 24 hour BP monitoring study, non-extended release HCTZ did not improve overall BP control. Chlorthalidone 6.25mg daily did, however.
J Am Coll Cardiol. 2016 Feb 2;67(4):379-89. doi: 10.1016/j.jacc.2015.10.083.
1Medical Affairs and Clinical Research, Ipca Laboratories Limited, Mumbai, India.
2Department of Cardiology, Mount Sinai Health Medical Center, Icahn School of Medicine, New York, New York; Department of Cardiology University Hospital, Bern, Switzerland. Electronic address: email@example.com.
3Clinical Research and Development, Ipca Laboratories Limited, Mumbai, India.
4Department of Medicine, King Edward Memorial Hospital, Pune, India.
5Department of Medicine, Rajiv Gandhi Medical College and Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane, India.
6Medilink Hospital and Research Centre, Ahmadabad, India.
7Dr. Kamal Sharma Cardiology Clinic, Ahmadabad, India.
8Department of Medicine, Dr. Sampurnanand Medical College and Mathura Das Mathur Hospital, Jodhpur, India.
9Omega Hospital, Mangalore, India.
Thiazide and thiazide-like diuretic agents are being increasingly used at lower doses. Hydrochlorothiazide (HCTZ) in the 12.5-mg dose remains the most commonly prescribed antihypertensive agent in the United States.
This study compared chlorthalidone, 6.25 mg daily, with HCTZ, 12.5 mg daily, by 24-h ambulatory blood pressure (ABP) monitoring and evaluated efficacy. Because HCTZ has been perceived as a short-acting drug, a third comparison with an extended-release formulation (HCTZ-controlled release [CR]) was added.
This 12-week comparative, double-blind, outpatient study randomized 54 patients with stage 1 hypertension to receive either chlorthalidone, 6.25 mg, (n = 16); HCTZ 12.5 mg (n = 18); or HCTZ-CR 12.5 mg (n = 20). ABP monitoring was performed at baseline and after 4 and 12 weeks of therapy.
All 3 treatments significantly (p < 0.01) lowered office BP at weeks 4 and 12 from baseline. At weeks 4 and 12, significant reductions in systolic and diastolic 24-h ambulatory and nighttime BP (p < 0.01) were observed with chlorthalidone but not with HCTZ. At weeks 4 (p = 0.015) and 12 (p = 0.020), nighttime systolic ABP was significantly lower in the chlorthalidone group than in the the HCTZ group. With HCTZ therapy, sustained hypertension was converted into masked hypertension. In contrast to the HCTZ group, the HCTZ-CR group also showed a significant (p < 0.01) reduction in 24-h ABP. All 3 treatments were generally safe and well tolerated.
Treatment with low-dose chlorthalidone, 6.25 mg daily, significantly reduced mean 24-h ABP as well as daytime and nighttime BP. Due to its short duration of action, no significant 24-h ABP reduction was seen with HCTZ, 12.5 mg daily, which merely converted sustained hypertension into masked hypertension. Thus, low-dose chlorthalidone, 6.25 mg, could be used as monotherapy for treatment of essential hypertension, whereas low-dose HCTZ monotherapy is not an appropriate antihypertensive drug. (Comparative Evaluation of Safety and Efficacy of Hydrochlorothiazide CR with Hydrochlorothiazide and Chlorthalidone in Patients With Stage I Essential Hypertension; CTRI/2013/07/003793).
Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID: 26821625 [PubMed - in process]
Journal of Emergency Medicine
- Edlow and Newman-Toker present a review article on HINTS testing for acute vertigo to distinguish central and peripheral.
- Patients with acetaminophen OD who did not complete 21-hour NAC IV protocol did very well, even if there were delays in starting treatment.
- Authors conclude that ED process improvements and a rapid assessment unit had a bigger impact on improving routine ED metrics, most notably Press-Ganey scores than did expansion of the ED size and number of beds. The problem is, the ED expansion happened first, followed by the process improvements. So it wasn't a true before/after. It was after/after. Because the ED was made bigger AND there were subsequent process improvements. So I am not sure what this study proves.
J Emerg Med. 2016 Feb 16. pii: S0736-4679(15)01254-8. doi: 10.1016/j.jemermed.2015.10.040. [Epub ahead of print]
1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
2The Johns Hopkins Hospital, Department of Neurology, The Johns Hopkins University School of Medicine, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.
Emergency department (ED) patients who present with acute dizziness or vertigo can be challenging to diagnose. Roughly half have general medical disorders that are usually apparent from the context, associated symptoms, or initial laboratory tests. The rest include a mix of common inner ear disorders and uncommon neurologic ones, particularly vertebrobasilar strokes or posterior fossa mass lesions. In these latter cases, misdiagnosis can lead to serious adverse consequences for patients.
Our aim was to assist emergency physicians to use the physical examination effectively to make a specific diagnosis in patients with acute dizziness or vertigo.
Recent evidence indicates that the physical examination can help physicians accurately discriminate between benign inner ear conditions and dangerous central ones, enabling correct management of peripheral vestibular disease and avoiding dangerous misdiagnoses of central ones. Patients with the acute vestibular syndrome mostly have vestibular neuritis, but some have stroke. Data suggest that focused eye movement examinations, at least when performed by specialists, are more sensitive for detecting early stroke than brain imaging, including diffusion-weighted magnetic resonance imaging. Patients with the triggered episodic vestibular syndrome mostly have benign paroxysmal positional vertigo (BPPV), but some have posterior fossa mass lesions. Specific positional tests to provoke nystagmus can confirm a BPPV diagnosis at the bedside, enabling immediate curative therapy, or indicate the need for imaging.
Emergency physicians can effectively use the physical examination to make a specific diagnosis in patients with acute dizziness or vertigo. They must understand the limitations of brain imaging. This may reduce misdiagnosis of serious central causes of dizziness, including posterior circulation stroke and posterior fossa mass lesions, and improve resource utilization.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26896289 [PubMed - as supplied by publisher]
J Emerg Med. 2016 Feb 15. pii: S0736-4679(15)01385-2. doi: 10.1016/j.jemermed.2015.12.004. [Epub ahead of print]
1Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada; Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York; Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.
2Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada; Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada; Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
3Departments of Emergency Medicine, and of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Ontario Poison Centre, Toronto, Ontario, Canada.
4Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
5Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute for Child & Maternal Health, Calgary, Alberta, Canada.
6Statistics Canada, Microdata Access Division, Prairie Regional Research Data Centre, University of Calgary, MLT-116, 2500 University Dr. NW, Calgary, Alberta, Canada.
7Division of Emergency Medicine, CHU Sainte Justine, Montreal, Quebec, Canada.
8Rocky Mountain Poison and Drug Center, Denver Hospital Health Authority, Denver, Colorado.
9Department of Emergency Medicine, Oregon Poison Center, Oregon Health & Science University, Portland, Oregon.
10Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado.
The minimum recommended treatment duration for i.v. N-acetylcysteine (NAC) after an acute, single acetaminophen (APAP) overdose is 21 h. Some have questioned whether shorter courses may be sufficient in carefully selected cases.
We sought to describe the incidence of hepatotoxicity in a cohort of acute APAP overdose patients who received <21 h of i.v. NAC for any reason.
We performed a secondary analysis of a large multicenter retrospective cohort of patients hospitalized for APAP poisoning. We selected patients with a potentially toxic serum APAP concentration measured between 4 and 24 h post ingestion, in whom i.v. NAC was initiated but discontinued before completing the full 21-h course. We further characterized outcomes in these patients as a function of two novel risk-prediction tools, the psi (ψ) parameter and APAP × aminotransferase (AT) product. The ψ parameter is an estimate of the cellular burden of injury based on the area under the concentration-time curve before treatment, and calculated with respect to the APAP concentration and time to initiation of NAC.
Fifty-nine patients met inclusion criteria. Intravenous NAC was initiated a median of 11.3 h post ingestion and administered for a median of 11.0 h. Hepatotoxicity (aspartate aminotransferase [AST] or alanine aminotransferase [ALT] > 1,000 IU/L) occurred in one patient (1.7%; 95% confidence interval 0.04-9.1), and eight additional patients developed hepatic injury (AST or ALT > 100 IU/L). No fatalities occurred. A multiplication product of APAP and AT (APAP × AT) that falls below 10,000 μmol/L/IU-L, or pretreatment ψ < 5 mmol/L-h suggested a low risk of hepatic injury.
In this retrospective analysis of patients treated with < 21 h of i.v. NAC for acute APAP overdose, the incidence of hepatotoxicity and coagulopathy was low, despite delays to NAC treatment.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26899513 [PubMed - as supplied by publisher]
J Emerg Med. 2016 Feb;50(2):339-48. doi: 10.1016/j.jemermed.2015.06.068. Epub 2015 Sep 14.
1Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts; Harvard Medical School, Boston, Massachusetts.
2Department of Emergency Medicine, Lahey Medical Center, Burlington, Massachusetts.
3Department of Emergency Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.
4Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both.
To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED.
This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis.
In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU.
Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26381804 [PubMed - in process]
Journal of Pediatrics
- Oral ondansetron in kids from 3 months to 5 years improved oral rehydration.
- Incision and drainage of pediatric patients with abscess is the mainstay, and kids who received 10 vs 3 days of TMP/SMX did even better, with fewer recurrences and failed treatment.
- Sensitivity for point-of-care ultrasound for diagnosing abscess (96%) was greater than physical exam (84%). Authors note that 1 of every 4 ultrasound tests changed and corrected management.
J Pediatr. 2016 Feb;169:105-109.e3. doi: 10.1016/j.jpeds.2015.10.006. Epub 2015 Dec 1.
1Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
2Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India. Electronic address: firstname.lastname@example.org.
3Department of Pharmacology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
To evaluate the role of oral ondansetron in facilitating successful rehydration of under-5-year-old children suffering from acute diarrhea with vomiting and some dehydration.
Children (n = 170) aged 3 months to 5 years with acute diarrhea with vomiting and some dehydration were enrolled in this double blind, randomized, placebo-controlled trial. The participants were randomized to receive either single dose of oral ondansetron (n = 85) or placebo (n = 85) in addition to standard management of dehydration according to World Health Organization guidelines. Failure of oral rehydration therapy (ORT), administration of unscheduled intravenous fluids, and amount of oral rehydration solution intake in 4 hours were the primary outcomes. Secondary outcome measures included duration of dehydration correction, number of vomiting episodes, adverse effects, and caregiver satisfaction.
Failure of ORT was significantly less in children receiving ondansetron compared with those receiving placebo (31% vs 62%; P < .001; relative risk 0.50, 95% CI 0.35-0.72). Almost one-half of the children in the ondansetron group received intravenous fluids compared with those in the placebo group, but it was not statistically significant (P = .074; relative risk 0.56, 95% CI 0.30-1.07). The oral rehydration solution consumption was significantly more in the ondansetron group (645 mL vs 554 mL; mean difference 91 mL; 95% CI: 35-148 mL). Patients in the ondansetron group also showed faster rehydration, lesser number of vomiting episodes, and better caregiver satisfaction.
A single oral dose of ondansetron, given before starting ORT to children <5 years of age with acute diarrhea and vomiting results in better oral rehydration.
Clinical Trial Registry of India: CTRI-2011/07/001916.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26654135 [PubMed - in process]
J Pediatr. 2016 Feb;169:128-134.e1. doi: 10.1016/j.jpeds.2015.10.044. Epub 2015 Nov 11.
1University at Buffalo, Buffalo, NY; Women & Children's Hospital of Buffalo, Buffalo, NY. Electronic address: LHolmes@upa.chob.edu.
2University at Buffalo, Buffalo, NY.
3Women & Children's Hospital of Buffalo, Buffalo, NY.
4University at Buffalo, Buffalo, NY; Women & Children's Hospital of Buffalo, Buffalo, NY.
To determine whether a 3-day vs 10-day course of antibiotics after surgical drainage of skin abscesses is associated with different failure and recurrence rates.
Patients age 3 months to 17 years seeking care at a pediatric emergency department with an uncomplicated skin abscess that required surgical drainage were randomized to receive 3 or 10 days of oral trimethoprim-sulfamethoxazole therapy. Patients were evaluated 10-14 days later to assess clinical outcome. Patients were followed for 6 months to determine the cumulative rate of recurrent skin infections.
Among the 249 patients who were enrolled, 87% of wound cultures grew Staphylococcus aureus (S aureus) (55% methicillin-resistant S aureus [MRSA], 32% methicillin-sensitive S aureus), 11% other organisms, and 2% no growth. Thirteen patients experienced treatment failure. Among all patients, no significant difference in failure rates between the 3- and 10-day treatment groups was found. After we stratified patients by the infecting organism, only patients with MRSA infection were more likely to experience treatment failure in the 3-day group than the 10-day group (P = .03, rate difference 10.1%, 95% CI 2.1%-18.2%) Recurrent infection within 1 month of surgical drainage was more likely in patients infected with MRSA who received 3 days of antibiotics. (P = .046, rate difference 10.3%, 95% CI 0.8%-19.9%).
Patients with MRSA skin abscesses are more likely to experience treatment failure and recurrent skin infection if given 3 rather than 10 days of trimethoprim-sulfamethoxazole after surgical drainage.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26578074 [PubMed - in process]
J Pediatr. 2016 Feb;169:122-127.e1. doi: 10.1016/j.jpeds.2015.10.026. Epub 2015 Nov 10.
1Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA. Electronic address: Cynthia.Adams@childrens.harvard.edu.
2Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
To determine the test characteristics of point-of-care ultrasonography for the identification of a drainable abscess and to compare the test characteristics of ultrasonography with physical examination. In addition, we sought to measure the extent to which ultrasonography impacts clinical management of children with skin and soft tissue infections (SSTIs).
We performed a prospective study of children with SSTIs evaluated in a pediatric emergency department. Treating physicians recorded their initial impression of whether a drainable abscess was present based on physical examination. Another physician, blinded to the treating physician's assessment, performed an ultrasound study and conveyed their interpretation and recommendations to the treating physician. Any management change was recorded. An abscess was defined as a lesion from which purulent fluid was expressed during a drainage procedure in the emergency department or during the 2- to 5-day follow-up period. We defined a change in management as correct when the ultrasound diagnosis was discordant from physical examination and matched the ultimate lesion classification.
Of 151 SSTIs evaluated among 148 patients, the sensitivity and specificity of point-of-care ultrasonography for the presence of abscess were 96% (95% CI 90%-99%) and 87% (74%-95%), respectively. The sensitivity and specificity of physical examination for the presence of abscess were 84% (75%-90%) and 60% (44%-73%), respectively. For every 4 ultrasound examinations performed, there was 1 correct change in management.
Point-of-care ultrasonography demonstrates excellent test characteristics for the identification of skin abscess and has superior test characteristics compared with physical examination alone.
Copyright © 2016 Elsevier Inc. All rights reserved.
PMID: 26563535 [PubMed - in process]
- A beta-lactam plus macrolide or appropriate fluoroquinolone within 4-8 hours was the best antibiotic choice in a large systematic review. Objective discharge criteria decreased length of stay.
- Sepsis has been redefined. The term severe sepsis is now considered redundant. Here is the new definition. "Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less."
- Septic shock has been redefined as well. Here is the consensus definition. "Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation."
- A third article discussed how SOFA score or quickSOFA is better than SIRS in determining who has sepsis.
- Do patients discharged from the ED who return and are admitted reflect poor quality ED care? This is currently a hospital performance measure and ED quality of care metric. IS this a fair metric? Authors found that patients admitted after initial ED discharge had "lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay" compared with patients admitted on their initial visit. We would expect that if important diagnoses were missed necessitating the return visit to the ED that patients would have worse outcomes. In fact, they do much better, suggesting that a return ED visit doesn't mean the hospital or ED did a bad job the first time. The editorial says, "The important question in the era of electronically enabled reporting is whether the return visit rate can be used as a marker of ED quality. The simple answer, long suspected and now clearly proven in the report by Sabbatini and colleagues in this issue of JAMA, is no."
JAMA. 2016 Feb 9;315(6):593-602. doi: 10.1001/jama.2016.0115.
1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania2Now with Division of General Internal Medicine, Department of Medicine, University of California, San Francisco.
2Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
3Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania3Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
Antibiotic therapy is the cornerstone of medical management for community-acquired pneumonia.
To assess the associations between 3 key aspects of antibiotic therapy (optimal time to antibiotic initiation, initial antibiotic selection, and criteria for the transition from intravenous to oral therapy) and short-term mortality in adults hospitalized with community-acquired pneumonia.
Bibliographic databases of MEDLINE, EMBASE, and the Cochrane Collaboration were searched for studies of adults hospitalized with radiographically confirmed community-acquired pneumonia published from January 1, 1995, until November 5, 2015.
Twenty studies (17 observational and 3 randomized trials) met eligibility criteria. Among 8 observational studies identified, the 4 largest (study populations of 2878 to 1,170,022) found that antibiotic initiation within 4 to 8 hours of hospital arrival was associated with relative reductions of 5% to 43% in mortality; the 4 smallest studies (study populations of 451 to 2076) found no associations between the timing of antibiotic initiation and mortality. One cluster randomized trial (n = 1737) demonstrated noninferiority of β-lactam monotherapy (n = 506) vs β-lactam plus macrolide combination therapy (n = 566), with an absolute adjusted difference of 2.5% (90% CI, -0.6% to 5.2%) in 90-day mortality favoring β-lactam monotherapy. A second randomized trial (n = 580) failed to demonstrate noninferiority of β-lactam monotherapy vs β-lactam plus macrolide combination therapy, with an absolute difference of 7.6% (1-sided 90% CI upper limit, 13.0%) in attainment of clinical stability on hospital day 7 favoring β-lactam plus macrolide combination therapy. Six of 8 observational studies (study populations of 1188 to 24,780) found that β-lactam plus macrolide combination therapy was associated with relative reductions of 26% to 68% in short-term mortality and all 3 observational studies (study populations of 2068 to 24,780) reported that fluoroquinolone monotherapy was associated with relative reductions of 30% to 43% in mortality compared with β-lactam monotherapy. One randomized trial (n = 302) reported significantly reduced hospital length of stay (absolute difference, 1.9 days; 95% CI, 0.6 to 3.2 days), but no differences in treatment failure when objective clinical criteria were used to decide when to transition patients from intravenous to oral therapy.
CONCLUSIONS AND RELEVANCE:
In adults hospitalized with community-acquired pneumonia, antibiotic therapy consisting of β-lactam plus macrolide combination therapy or fluoroquinolone monotherapy initiated within 4 to 8 hours of hospital arrival was associated with lower adjusted short-term mortality, supported predominantly by low-quality observational studies. One randomized trial supports the use of objective clinical criteria to guide the transition from intravenous to oral antibiotic therapy.
PMID: 26864413 [PubMed - indexed for MEDLINE]
JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
Singer M1, Deutschman CS2, Seymour CW3, Shankar-Hari M4, Annane D5, Bauer M6, Bellomo R7, Bernard GR8, Chiche JD9, Coopersmith CM10, Hotchkiss RS11, Levy MM12, Marshall JC13, Martin GS14, Opal SM12, Rubenfeld GD15, van der Poll T16, Vincent JL17, Angus DC18.
1Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom.
2Hofstra-Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York.
3Department of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
4Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
5Department of Critical Care Medicine, University of Versailles, France.
6Center for Sepsis Control and Care, University Hospital, Jena, Germany.
7Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, and Austin Hospital, Melbourne, Victoria, Australia.
8Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, Tennessee.
9Réanimation Médicale-Hôpital Cochin, Descartes University, Cochin Institute, Paris, France.
10Critical Care Center, Emory University School of Medicine, Atlanta, Georgia.
11Washington University School of Medicine, St Louis, Missouri.
12Infectious Disease Section, Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, Rhode Island.
13Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
14Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia.
15Trauma, Emergency & Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada16Interdepartmental Division of Critical Care, University of Toronto.
16Department of Infectious Diseases, Academisch Medisch Centrum, Amsterdam, the Netherlands.
17Department of Intensive Care, Erasme University Hospital, Brussels, Belgium.
18Department of Critical Care Medicine, University of Pittsburgh and UPMC Health System, Pittsburgh, Pennsylvania20Associate Editor, JAMA.
Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination.
To evaluate and, as needed, update definitions for sepsis and septic shock.
A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment).
KEY FINDINGS FROM EVIDENCE SYNTHESIS:
Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant.
Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.
CONCLUSIONS AND RELEVANCE:
These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.
PMID: 26903338 [PubMed - indexed for MEDLINE]
JAMA. 2016 Feb 23;315(8):775-87. doi: 10.1001/jama.2016.0289.
Angus D, Annane D, Bauer M, Bellomo R, Bernard G, Chiche JD, Coopersmith C, Deutschman C, Hotchkiss R, Levy M, Marshall J, Martin G, Opal S, Rubenfeld G, Seymour C, Shankar-Hari M, Singer M, van der Poll T, Vincent JL.
1Division of Asthma, Allergy, and Lung Biology, King's College London, London, United Kingdom2Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE17EH, United Kingdom.
2The Ohio State University College of Medicine, Department of Biomedical Informatics, Center for Biostatistics, Columbus.
3Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island.
4Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
5Division of Research, Kaiser Permanente, Oakland, California.
6Department of Pediatrics, Hofstra-North Shore-Long Island Jewish-Hofstra School of Medicine, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York8Department of Molecular Medicine, Hofstra-North Shore-Long Island Jewish-Hofstra Sch.
7Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania10Associate Editor, JAMA.
8Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada12Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
9Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom.
Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition.
To develop a new definition and clinical criteria for identifying septic shock in adults.
DESIGN, SETTING, AND PARTICIPANTS:
The Society of Critical Care Medicine and the European Society of Intensive Care Medicine convened a task force (19 participants) to revise current sepsis/septic shock definitions. Three sets of studies were conducted: (1) a systematic review and meta-analysis of observational studies in adults published between January 1, 1992, and December 25, 2015, to determine clinical criteria currently reported to identify septic shock and inform the Delphi process; (2) a Delphi study among the task force comprising 3 surveys and discussions of results from the systematic review, surveys, and cohort studies to achieve consensus on a new septic shock definition and clinical criteria; and (3) cohort studies to test variables identified by the Delphi process using Surviving Sepsis Campaign (SSC) (2005-2010; n = 28,150), University of Pittsburgh Medical Center (UPMC) (2010-2012; n = 1,309,025), and Kaiser Permanente Northern California (KPNC) (2009-2013; n = 1,847,165) electronic health record (EHR) data sets.
MAIN OUTCOMES AND MEASURES:
Evidence for and agreement on septic shock definitions and criteria.
The systematic review identified 44 studies reporting septic shock outcomes (total of 166,479 patients) from a total of 92 sepsis epidemiology studies reporting different cutoffs and combinations for blood pressure (BP), fluid resuscitation, vasopressors, serum lactate level, and base deficit to identify septic shock. The septic shock-associated crude mortality was 46.5% (95% CI, 42.7%-50.3%), with significant between-study statistical heterogeneity (I2 = 99.5%; τ2 = 182.5; P < .001). The Delphi process identified hypotension, serum lactate level, and vasopressor therapy as variables to test using cohort studies. Based on these 3 variables alone or in combination, 6 patient groups were generated. Examination of the SSC database demonstrated that the patient group requiring vasopressors to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L (18 mg/dL) after fluid resuscitation had a significantly higher mortality (42.3% [95% CI, 41.2%-43.3%]) in risk-adjusted comparisons with the other 5 groups derived using either serum lactate level greater than 2 mmol/L alone or combinations of hypotension, vasopressors, and serum lactate level 2 mmol/L or lower. These findings were validated in the UPMC and KPNC data sets.
CONCLUSIONS AND RELEVANCE:
Based on a consensus process using results from a systematic review, surveys, and cohort studies, septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.
PMID: 26903336 [PubMed - indexed for MEDLINE]
JAMA. 2016 Feb 23;315(8):762-74. doi: 10.1001/jama.2016.0288.
1Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania2Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania.
2Division of Research, Kaiser Permanente, Oakland, California.
3Department of Internal Medicine, University of Michigan, Ann Arbor5Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan6Australia and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine.
4Center for Clinical Studies, Jena University Hospital, Jena, Germany.
5Division of General Internal Medicine, University of Washington, Seattle.
6Research Group Clinical Epidemiology, Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.
7Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
8Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, England.
9Bloomsbury Institute of Intensive Care Medicine, University College London, London, England.
10Feinstein Institute for Medical Research, Hofstra-North Shore-Long Island Jewish School of Medicine, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York.
The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown.
To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis.
DESIGN, SETTINGS, AND POPULATION:
Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706,399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013.
Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100 mm Hg], tachypnea [≥22/min], or altered mentation).
MAIN OUTCOMES AND MEASURES:
For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC).
In the primary cohort, 148,907 encounters had suspected infection (n = 74,453 derivation; n = 74,454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome.
CONCLUSIONS AND RELEVANCE:
Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.
PMID: 26903335 [PubMed - indexed for MEDLINE]
JAMA. 2016 Feb 16;315(7):663-71. doi: 10.1001/jama.2016.0649.
1Division of Emergency Medicine, University of Washington, Seattle.
2Department of Emergency Medicine, University of Michigan, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
3Department of Health Services and Economics, University of Washington, Seattle.
4Department of Emergency Medicine, University of California, San Francisco6Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.
To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED.
DESIGN, SETTING, AND PARTICIPANTS:
Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days.
Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED.
MAIN OUTCOMES AND MEASURES:
In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs.
Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit.
CONCLUSIONS AND RELEVANCE:
Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.
PMID: 26881369 [PubMed - indexed for MEDLINE]
Most children with bronchiolitis sent home with pulse oximeters had frequent sustained desaturations, but there was no difference in return visits or repeat hospitalization in those with desaturations vs those without. I guess the parents just didn't get worked up about it. I don't know what to do with this information. I still plan to admit children with sustained oxygen desaturation.
JAMA Pediatr. 2016 Feb 29. doi: 10.1001/jamapediatrics.2016.0114. [Epub ahead of print]
1Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada2Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
2Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
3Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay, and escalation of care.
To examine whether there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who have oxygen desaturations to lower than 90% for at least 1 minute during home oximetry monitoring vs those without desaturations.
Design, Setting, and Participants:
Prospective cohort study conducted from February 6, 2008, to April 30, 2013, at a tertiary care pediatric emergency department in Toronto, Ontario, Canada, among 118 otherwise healthy infants aged 6 weeks to 12 months discharged home from the emergency department with a diagnosis of acute bronchiolitis.
Main Outcomes and Measures:
The primary outcome was unscheduled medical visits for bronchiolitis, including a visit to any health care professional due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge, and the effect of activity on desaturations.
A total of 118 infants were included (mean [SD] age, 4.5 [2.1] months; 69 male [58%]). During a mean (SD) monitoring period of 19 hours 57 minutes (10 hours 37 minutes), 75 of 118 infants (64%) had at least 1 desaturation event (median continuous duration, 3 minutes 22 seconds; interquartile range, 1 minute 54 seconds to 8 minutes 50 seconds). Among the 118 infants, 59 (50%) had at least 3 desaturations, 12 (10%) had desaturation for more than 10% of the monitored time, and 51 (43%) had desaturations lasting 3 or more minutes continuously. Of the 75 infants who had desaturations, 59 (79%) had desaturation to 80% or less for at least 1 minute and 29 (39%) had desaturation to 70% or less for at least 1 minute. Of the 75 infants with desaturations, 18 (24%) had an unscheduled visit for bronchiolitis as compared with 11 of the 43 infants without desaturation (26%) (difference, -1.6%; 95% CI, -0.15 to ∞; P = .66). One of the 75 infants with desaturations (1%) and 2 of the 43 infants without desaturations (5%) were hospitalized within 72 hours (difference, -3.3%; 95% CI, -0.04 to 0.10; P = .27). Among the 62 infants with desaturations who had diary information, 48 (77%) experienced them during sleep or while feeding.
Conclusions and Relevance:
The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.
PMID: 26928704 [PubMed - as supplied by publisher]
This is a big meta-analysis of the recent trials looking at endovascular thrombectomy, and it showed that this is a good thing. NNT to improve one level on the modified Rankin Scale is 2.6. Do it if you can in patients with proximal occlusion of the anterior circulation.
Lancet. 2016 Feb 18. pii: S0140-6736(16)00163-X. doi: 10.1016/S0140-6736(16)00163-X. [Epub ahead of print]
Goyal M1, Menon BK1, van Zwam WH2, Dippel DW3, Mitchell PJ4, Demchuk AM1, Dávalos A5, Majoie CB6, van der Lugt A3, de Miquel MA7, Donnan GA8, Roos YB6, Bonafe A9, Jahan R10, Diener HC11, van den Berg LA6, Levy EI12, Berkhemer OA6, Pereira VM13, Rempel J14, Millán M15, Davis SM16, Roy D17, Thornton J18, Román LS19, Ribó M20, Beumer D2, Stouch B21, Brown S22, Campbell BC16, van Oostenbrugge RJ2, Saver JL23, Hill MD1, Jovin TG24; HERMES collaborators.
1Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada.
2Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands.
3Erasmus MC University Medical Center, Rotterdam, Netherlands.
4Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia.
5Hospital Germans Trias y Pujol, Barcelona, Spain.
6Academic Medical Center, Amsterdam, Netherlands.
7Hospital de Bellvitge, Barcelona, Spain.
8Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.
9Hospital Guy de Chaulliac, Montpellier, France.
10UCLA Medical Center, Los Angeles, CA, USA.
11Department of Neurology, University Hospital Essen, Essen, Germany.
12State University of New York, Buffalo, Buffalo, NY, USA.
13University of Toronto, Toronto, ON, Canada.
14University of Edmonton, Edmonton, AB, Canada.
15Hospital Germans Trials y Pujol, Barcelona, Spain.
16Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia.
17CHUM Notre-Dame Hospital, Montreal, QC, Canada.
18Beaumont Hospital, Dublin, Ireland.
19Hospital Clinic, Barcelona, Spain.
20Hospital Vall d'Hebron, Barcelona, Spain.
21Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.
22Altair Biostatistics, St Louis Park, MN, USA.
23David Geffen School of Medicine, University of Los Angeles, Los Angeles, CA, USA.
24University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, Pittsburgh, PA, USA. Electronic address: email@example.com.
In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included.
We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation.
We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2·49, 95% CI 1·76-3·53; p<0·0001). The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2·6. Subgroup analysis of the primary endpoint showed no heterogeneity of treatment effect across prespecified subgroups for reduced disability (pinteraction=0·43). Effect sizes favouring endovascular thrombectomy over control were present in several strata of special interest, including in patients aged 80 years or older (cOR 3·68, 95% CI 1·95-6·92), those randomised more than 300 min after symptom onset (1·76, 1·05-2·97), and those not eligible for intravenous alteplase (2·43, 1·30-4·55). Mortality at 90 days and risk of parenchymal haematoma and symptomatic intracranial haemorrhage did not differ between populations.
Endovascular thrombectomy is of benefit to most patients with acute ischaemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. These findings will have global implications on structuring systems of care to provide timely treatment to patients with acute ischaemic stroke due to large vessel occlusion.
Copyright © 2016 Elsevier Ltd. All rights reserved.
PMID: 26898852 [PubMed - as supplied by publisher]
New England Journal of Medicine
Duty hour restrictions in surgical residents did not improve patient care or improve resident work satisfaction.
N Engl J Med. 2016 Feb 25;374(8):713-727. Epub 2016 Feb 2.
1From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine and Northwestern Medicine, Northwestern University (K.Y.B., J.W.C., A.R.D., R.L., A.D.Y., D.M.M., D.D.O., J.J.S.), and the American College of Surgeons (K.Y.B., M.E.C., D.B.H., C.Y.K.), Chicago, the Department of Statistics, Northwestern University, Evanston (L.V.H.), and the Department of Surgery, Southern Illinois University, Springfield (J.D.M.) - all in Illinois; the Department of Surgery, Vanderbilt University, Nashville (J.L.T.); the Department of Surgery and the Center for Surgery and Health Economics, Perelman School of Medicine, University of Pennsylvania (R.R.K.), and the American Board of Surgery (F.R.L.) - both in Philadelphia; and the Department of Surgery, University of California, Los Angeles, School of Medicine, Los Angeles (C.Y.K.).
Background Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being. Methods We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care. Results In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001). Conclusions As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789 .).
PMID: 26836220 [PubMed - as supplied by publisher]
Pediatric Critical Care Medicine
Patients receiving magnesium sulfate 50mg/kg over 4 hours vs over 1 hour in severe asthma not improving after 2h standard therapy were discharged home within 24 hours more often and had shorter LOS. This is counterintuitive.
Pediatr Crit Care Med. 2016 Feb;17(2):e29-33. doi: 10.1097/PCC.0000000000000581.
11Wolfson Children's Hospital, Jacksonville, FL. 2Hospital General Pediátrico Niños de Acosta Ñu, Asunción, Paraguay.
To assess the efficacy of a high-dose prolonged magnesium sulfate infusion in patients with severe, noninfectious-mediated asthma.
Prospective, randomized, open-label study.
Twenty-nine-bed pediatric emergency department located in a children's hospital in Asuncion, Paraguay.
All patients of 6-16 years old who failed to improve after 2 hours of standard therapy for asthma.
Subjects were randomized to receive magnesium sulfate, 50 mg/kg over 1 hour (bolus) or high-dose prolonged magnesium sulfate infusion of 50 mg/kg/hr for 4 hours (max, 8.000 mg/4 hr). Patients were monitored for cardiorespiratory complications.
MEASUREMENTS AND MAIN RESULTS:
Asthma severity was assessed via asthma scores and peak expiratory flow rates at 0-2-6 hours. The primary outcome was discharge to home at 24 hours. An analysis of the hospital length of stay and costs was a secondary outcome. Thirty-eight patients were enrolled, 19 in each group. The groups were of similar ages, past medical history of asthma, asthma score, and peak expiratory flow rate. There was a significant difference in the patients discharged at 24 hours: 47% in high-dose prolonged magnesium sulfate infusion (9/19) versus 10% (2/21) in the bolus group (p = 0.032) with an absolute risk reduction 37% (95% CI, 10-63) and a number needed to treat of 2.7 (95% CI, 1.6-9.5) to facilitate a discharge at or before 24 hours. The length of stay was shorter in the high-dose prolonged magnesium sulfate infusion group (mean ± SD in hr: high-dose prolonged magnesium sulfate infusion, 34.13 ± 19.54; bolus, 48.05 ± 18.72; p = 0.013; 95% CI, 1.3-26.5). The cost per patient in the high-dose prolonged magnesium sulfate infusion group was one third lower than the bolus group (mean ± SD: high-dose prolonged magnesium sulfate infusion, $603.16 ± 338.47; bolus, $834.37 ± 306.73; p < 0.016). There were no interventions or discontinuations of magnesium sulfate due to adverse events.
The early utilization of high-dose prolonged magnesium sulfate infusion (50 mg/kg/hr/4 hr), for non-infectious mediated asthma, expedites discharges from the emergency department with significant reduction in healthcare cost.
PMID: 26649938 [PubMed - in process]
Prehospital Emergency Care
Seventy percent of EMS personnel have experienced violence on the job, either physical or verbal. Busy, urban paramedics and EMTs faced it the most often. The ED is rough, but it's even tougher on the streets where these colleagues and friends work. Be sure to thank your EMS pros!
Prehosp Emerg Care. 2016 Feb 2:1-9. [Epub ahead of print]
EMS personnel often work in unpredictable environments and are at high risk for sustaining occupational injuries. One potential source of injury that is of growing concern is violence toward EMS personnel.
To describe the prevalence of violence directed at EMS personnel by type and source, and to identify characteristics associated with experiencing violence.
The 2013 Longitudinal EMT Attributes and Demographics Study contained 14 items assessing violence experienced in the past 12 months. Violence was categorized by type (physical or verbal) and by source (the patient or a patient's family member or bystander). EMS personnel characteristics included sex, age, race, marital status, certification level, firefighter, volunteerism, agency type, and community size. Descriptive and comparative analyses were performed on personnel whose primary role was providing patient care. Multivariable logistic regression modelling was used to assess associations between provider characteristics and experiencing violence.
A total of 2,515/4,238 (59.3%) responses were received and 1,789 met inclusion criteria. Over two-thirds (69.0%) experienced at least one form of violence in the past 12 months. Verbal violence was more prevalent than physical (67.0% vs. 43.6%). Using multivariable logistic regression to control for other demographic and employment characteristics, paramedics had nearly triple the odds of experiencing physical (OR = 2.67, 95% CI = 2.06-3.46) and verbal (OR = 2.63, 95% CI = 1.99-3.46) violence as EMTs. Urban personnel had increased odds of experiencing physical (OR = 1.53, 95% CI = 1.21-1.93) and verbal violence (OR = 1.32, 95% CI = 1.02-1.71). Each additional weekly transport increased the odds of experiencing physical (OR = 1.04, 95% CI = 1.03-1.05) and verbal (OR = 1.04, 95% CI = 1.03-1.06) violence by 4%. Those who were volunteers at their main EMS jobs had decreased odds of experiencing physical (OR = 0.68, 95% CI = 0.50-0.92) and verbal (OR = 0.59, 95% CI = 0.44-0.78) violence.
Over two-thirds of EMS personnel experienced at least one form of violence in the last 12 months. Demographic and employment characteristics associated with experiencing violence were identified. Our findings may be used in education initiatives to raise awareness of the high prevalence of violence toward EMS personnel and factors associated with experiencing violence.
PMID: 26836247 [PubMed - as supplied by publisher]
Similar to last month's article in Resuscitation, only 1% of patients (with shockable and non-shockable rhythms) survived when CPR was continued past 48 minutes. Those with shockable rhythm had better ROSC and neurologically intact survival than non-shockable even with longer CPR time.
Resuscitation. 2016 Feb 3;101:50-56. doi: 10.1016/j.resuscitation.2016.01.021. [Epub ahead of print]
1UBC Department of Emergency Medicine, Vancouver, B.C., Canada; St Paul's Hospital, Vancouver, B.C., Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, B.C., Canada; UBC School of Population and Public Health, Vancouver, B.C., Canada. Electronic address: Brian.Grunau2@vch.ca.
2Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, United States.
3UBC Department of Emergency Medicine, Vancouver, B.C., Canada; St Paul's Hospital, Vancouver, B.C., Canada.
4UBC Department of Emergency Medicine, Vancouver, B.C., Canada; St Paul's Hospital, Vancouver, B.C., Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, B.C., Canada; UBC School of Population and Public Health, Vancouver, B.C., Canada.
5Providence Healthcare Research Institute, Vancouver, B.C., Canada.
6UBC Department of Medicine, Vancouver, B.C., Canada.
7UBC Division of General Surgery, Vancouver, B.C., Canada.
8UBC Division of Cardiology, Vancouver, B.C., Canada.
There is little data to inform the appropriate duration of resuscitation attempts for out-of-hospital cardiac arrest (OHCA). We assessed the relationship of elapsed duration since commencement of resuscitation and outcomes, highlighting differences between initial shockable and non-shockable rhythms.
We examined consecutive adult non-traumatic EMS-treated OHCA in a single health region. We plotted the time-dependent accrual of patients with ROSC, as well as dynamic estimates of outcomes as a function of duration from commencement of professional resuscitation, and compared subgroups dichotomized by initial rhythm. Logistic regression tested the association between time-to-ROSC and outcomes.
Of 1627 adult EMS-treated cases of OHCA, 1617 patients were included; 14% survivors and 10% with favorable neurological outcomes. Time-to-ROSC (per minute increase) was independently associated with survival in those with initial shockable (aOR 0.95, 95% CI 0.92-0.97) and non-shockable (aOR 0.83; 95% CI 0.78-0.88) rhythms. Similar associations were seen with favorable neurologic outcome. The elapsed duration at which the probability of survival fell below 1% was 48 and 15min in the shockable and non-shockable groups, respectively. Median time-to-termination of resuscitation was 36 and 26min in the shockable and non-shockable groups, respectively.
The subgroup of initial shockable rhythms showed a less pronounced association of time-to-ROSC with outcomes, and demonstrated higher resilience for neurologically intact survival after prolonged periods of resuscitation. This data can guide minimum durations of resuscitation, however should not be considered as evidence for termination of resuscitation as survival in this cohort may have been improved with longer resuscitation attempts.
Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
PMID: 26851705 [PubMed - as supplied by publisher]