tc ed wrap up

TC’s Wrap UpA potpourri of the blogosphere, grand rounds

and interesting stuff

30/4/2015

International Symposium on Intensive Care and Emergency Medicine Update

• 3 big studies

– ProMISe

– ABLE

– SIRS Criteria in Sepsis

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ProMISe

• In a pragmatic, open, parallel group, randomized controlled trial, Mouncey and colleagues compared an early goal-directed therapy protocol for the first six hours of management (n=630) with usual care (n=630), in 1260 patients with early septic shock across 56 English hospitals

ProMISe

• EGDT– A central venous catheter capable of continuous SCVO2 measurement (Edwards

Lifesciences Ltd) Controversial and arterial line was inserted– A treatment algorithm was commenced based on Rivers' original EGDT algorithm &

included:• Supplemental oxygen if not already initiated and titrated to achieve SpO2 > 93%• 500mls bolus of crystalloid or colloid at least every 30 minutes until CVP > 8mmHg • Vasopressors to achieve MAP of > 65 and/or SBP > 90mmHg• SCVO2 >70% once CVP and MAP targets achieved

– If SCVO2 < 70% and Hb < 100g/dl → packed red cells– If SCVO2 < 70% and Hb > 100g/dl → dobutamine 2.5–20mcg/kg/min– If SCVO2 still < 70% → increase oxygen → NIV → Mechanical ventilation

» Sedative and paralysing agents used if mechanically ventilated

• Treatment algorithm continued for 6 hours. At the end of six hours, the patient returns to standard care and continuous SCVO2 monitoring was no longer mandated.

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Dodgy

ProMISe

• Control

• Usual Care– Arterial line and a CVC may be inserted if

considered clinically appropriate

– SCVO2 measurement was not permitted during the 6 hour intervention period

– Decisions about the location of care delivery, investigations, monitoring, and all treatments were made at the discretion of the treating clinician

ProMISe

• Comparing EGDT vs usual care interventions

• Insertion of central venous catheter: 92.1% vs. 50.9%

• Arterial line insertion: 74.2% vs. 62.2%

• Vasopressor use: 53.3% vs 46.6%

• Dobutamine use: 18.1% vs 3.8%

• Red cell transfusion: 8.8% vs 3.8%

• Advanced respiratory support: 28.9% vs 28.5%

• ICU admission: 88.2% vs 74.6%

ProMISe

• EGDT vs UC

– No difference in 90 day mortality (29.5%vs29.2%)

– Worsened organ failure with EGDT

– Increased resource usage with EGDT• Vasoactive drugs, red cell transfusions, advanced

circulatory support, LOS in ICU

– No benefit seen for EGDT was seen in any subgroup

– No difference in adverse events

ABLE

• In a parallel group, blinded, randomized controlled trial, Lacroix and colleagues compared transfusion of fresh red cells (stored for < 8 days, n=1211) with standard-issue red cells (the oldest compatible units available in the blood bank, n=1219) in 2,400 critically ill

ABLE

• No difference in 90 day mortality

• No significant differences in any secondary outcome

– Death, LOS, transfusion reactions

SIRS Criteria in Sepsis

• Kaukonen and colleagues tested the utility of the SIRS criteria for the identification of severe sepsis using data from 1,171,797 patients, of whom 109,663 had infection and organ failure, over a 14 year period (2000 to 2013) from 172 ICUs in New Zealand and Australia


• SIRS criteria

– 1. Body temperature >38°C or <36°C

– 2. Heart rate >90/minute

– 3. Respiratory rate >20/minute or PaCO2 lower than 32mmHg (4.3kPa)

– 4. White blood cell count >12000/μL (>12x109/L) or <4000/μL (<4x109/L)

• When 2 or more criteria are present


• Percentage breakdown – SIRS-positive severe sepsis: 87.9% (n=96,385)– SIRS-negative severe sepsis: 12.1% (n=13,278)

• patients with SIRS-positive severe sepsis were – younger

• 65.8 vs 68.3; p<0.001

– more severely ill • APACHE III score

– 73.7±30.1 vs 56.7±26.1; p<0.001

– suffered higher mortality • 24.5% vs 16.1%; p<0.001

– suffered greater organ failure • septic shock

– 58% vs 42.2%; p<0.001

• acute renal failure – 18.9% vs 11.7%; p<0.001

– reduced rates of • mechanical ventilation

– 53.3% vs 55.2%; p<0.001


• both groups had decreasing mortality over this time period – SIRS-positive group:

• from 36.1% to 18.3%, p<0.001

– SIRS-negative group: • from 27.7% to 9.3%, p<0.001

• adjusted mortality increased linearly with each additional SIRS criterion – odds ratio for each additional criterion 1.13 (95% CI 1.11 to

1.15; P<0.001)– without any transitional increase in risk at a threshold of two

SIRS criteria


• The authors concluded

– "The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality, and failed to define a transition point in the risk of death."


• The traditional SIRS-criteria definition of severe sepsis, previously thought to have at least sensitivity at expense of specificity will miss 1 in 8 patients with organ failure and an underlying infection.

• Considering only approximately 1/3rd of patients with two or more SIRS criteria in the Emergency Department have an underlying infection, the utility of these criteria is substantially less reliable than previously thought.

• Code Sepsis anyone?

Thrombolysis in acute ischaemic stroke: time for a rethink?

• BMJ March 2015• Use of alteplase 3-4.5 hours after stroke is supported by

guidelines and meta-analyses based on analyses that do not directly examine treatment in this time frame

• Direct comparisons of alteplase with no alteplase at 3-4.5 hours after stroke suggest an absolute increase in mortality of 2% and no clear benefit

• Recommendations to use alteplase 3-4.5 hours after stroke should be re-evaluated

I want a copy of the consent the neurologists use before thrombolysis

Chronic Digoxin Toxicity

Chronic Digoxin Toxicity

• Normal range can be anywhere from 0.5-2.0ug/L

• Risk of CDT is derived from level plus signs and symptoms

• How much Digibind?

• Number of vials=Dig level x weight/100

Or 2 vials

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RTA

Type Type 1 Type 2 Type 4

Location Distal tubules Proximal tubules Adrenal

Acidosis? Yes (severe) Yes Mild if at all

Potassium

Pathophysiology Failure of H+ secretion by the α intercalated cells and reclaim K

Failed HCO3−

reabsorption from the urine by the proximal tubular cells

Deficiency of aldosterone, or a resistance to its effects, (hypoaldosteronism, pseudohypoaldosteronism)

Mr S

• K+ is 7.8

• Urine pH 5.03

– RTA type 1 cannot acidify urine below pH 5.3

• On ACEi and spironolactone

RCL

• Residential Care Line

• Like HITH but for people in an aged care facility

• Has a NP

• Can deal with UTIs, constipation, dementia MX, etc

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Dihydrofolate reductase inhibitors• Methotrexate

• RA, Crohn’s, psoriasis, etc

• Trimethoprim +/- sulfamethoxazole

• Infections - UTI, prevent PCP, etc.

• High potential for concurrent use in patients

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• Why such a disparity in uses?

• Mammalian vs bacterial dihydrofolate reductase inhibitors

• Potential for lethal interaction - through pancytopenia causing overwhelming sepsis

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Tibial nerve block

• Most of sole of foot supplied by tibial nerve

• relatively easy and effective nerve block

• poor success rates without USS

• Volunteer?

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You don’t need the K-Hole

• 0.3mg/kg of ketamine (sub-dissociative dose) shows comparable efficacy and safety to IV morphine

• For opioid resistant/tolerant pain

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Here is the video link: http://emcrit.org/wee/real-surgical-airway/

http://emcrit.org/wee/real-surgical-airway/

Foots

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C8573677

Not Anne Frank’s sister

• Jacques Lisfranc de St. Martin

• 1829-1893

• French SurgeonSurgeon in Napoleon’s army who described an amputation method through the tarsometatarsal joints

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50% sensitivity non-WB XRs

• Lisfranc injury refers to disruption of the tarsometatarsal joint. Injuries range from sprain (minor diastasis) through to tarsometatarsal fracture-dislocation.The presence of small avulsed fragments (fleck sign) are further indications of ligamentous injury and probable joint disruption

• Examples of this type of trauma include a rider falling from a horse but the foot remaining trapped in the stirrup, or a person falling forward after stepping into a storm drain.

• low threshold to CT 39

Fatties

• The “Obesity” Paradox

• There is evidence that obese patients have equal or even a reduced mortality compared to non-obese cohorts

• Theories to explain the obesity paradox

• Increased nutritional reserves (e.g. adipose tissue) that may deal with inflammation and metabolic stress

• Patients may receive more aggressive care than their normal weight cohorts

• The severely obese may be a younger cohort of patients and may skew the data

• Sample size of critically ill obese patients still too small to conclude from studies

• Obese patients may have increased:

• duration of intubation and mechanical ventilation

• longer length of ICU stay 43

Señor Chunkos

• Inaccuracies in assessing blood pressure secondary to improper cuff size

• A small bladder cuff may overestimate blood pressure by up to 50 mmHg

• Appropriate bladder length should be at least 75% of upper arm circumference and a width greater than 50% the length of the upper arm

• Difficulty in obtaining peripheral intravenous access even with ultrasound assistance

• Difficulty in obtaining or interpreting diagnostic imaging

• Limitations of ultrasound

• Underpenetrated X-rays

• Weight limits of CT/MRI machines

• Appropriate and therapeutic dosing of medications is challenging

• Larger volume of distribution for lipophilic drugs

• Increased clearance of hydrophilic drugs

• Reduction in lean body mass and tissue water

• An overall understanding that drugs differ by the way they should be dosed

• Ideal body weight?

• Total body weight?

• Dosing weight?

• Consider using clinical pharmacologists when you have them either available in person or by phone

• Procedures can be difficult and increased risks of complications. Examples:

• Endotracheal intubation

• Central line placement

• Thoracostomy 44

Chunky Monkeys• Differences in airway anatomy in the critically ill obese patient

• Attempts at intubation are more challenging and have an increased risk of failure

• Increased oropharyngeal tissue / Mallampati (III-IV)

• Small oral opening

• Limited neck flexibility

• Increased neck circumference

• Pulmonary changes in the critically ill obese patient

• Restrictive physiologic pattern secondary to a reduction in chest wall compliance

• Increased adipose tissue surrounding chest wall, diaphragm, and abdomen

• Increased pressure on anterior chest from adipose tissue

• Increased airway resistance

• Para-pharyngeal fat deposition

• Fibrosis from chronic airways changes

• Repetitive opening and closing of small airways

• Respiratory muscles endure an increased workload and oxygen consumption

• Reduction in lung volumes

• Total Lung Capacity

• Functional residual capacity

• Vital Capacity

• Expiratory reserve volume

• Intrapulmonary shunting

• V/Q mismatch

• All of the above changes may lead to severe hypoxemia, hypercarbia, and rapid desaturation during intubation

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Tubbies

•All of the above changes may lead to severe hypoxemia, hypercarbia, and rapid desaturation during intubation

•Plan ahead!46

Lest we forget

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tc ed wrap up

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