Improving Throughput, Mythbusting

More No-Value Care: pre-procedure INR for cirrhotics

You have a cirrhotic patient in front of you. They need a procedure. You reflexively order a cbc, comprehensive metabolic panel, and PT/INR because you’d like to know about their platelets/ liver enzymes / coagulation ability.

Or maybe it’s a consultant who refuses to do a procedure the patient needs until you order these tests.

And then the platelets come back at 40; or maybe the INR returns at 1.4. Now what?

Do we need to transfuse platelets or FFP? Well, this case series looked at 852 consecutive cirrhotics from Jan ’11 – March ’14 who needed an invasive procedure the decision to transfuse PLT / FFP at attending discretion. Here’s a breakdown of their patient demographics:


And the number of complications:


Now, sadly, despite discussing the World Health Organization classification for bleeding events, they did not really get into the severity of bleeding events. With that said, complications were unrelated to platelet count, INR, CHILD classes, and MELD score. Only 1 in 379 paracentesis had a bleeding event, and only 2 of 228 TIPS/ CVC/ PICC/ hemodialysis/ I&D procedures had an event.

Perhaps most importantly, while attempts to normalized PLT and INR values, PLT/FFP transfusions barely affected the corresponding abnormalities, the scheduled invasive investigations were carried out in the presence of still subnormal parameters- with no or only a few bleeding complications.

Ergo, I agree with the authors, – “we have verified clinically the futility of this recommendation.”

Critical Care, Improving Outcomes, Mythbusting, Neurology

Compazine… for infectious disease?

Today’s article’s (1, 23 ) are a break from the usual trials that are typically discussed and a bit more “benchside medicine” than bedside medicine.  In fact, let’s look at this as an early request for one of the 12 trials of Christmas.

Phenothiazines have demonstrated in vitro (as well as some in vivo) activity for gram positive cocci, mycobacteria, amoeba (4; 5), and some gram negative rods.

It should be noted that Klebsiellae, pseudomonads and acenetobacters were highly resistant to almost all of these drugs.

The MIC for phenothiazines are usually not reached with conventionally used doses, but these compounds do enhance the activity of various antibiotics to which various bacteria are susceptible (including vancomycin), and even decrease the MIC of resistant organisms.

So where am I going with all of this? For starters, lets look at some common causes of meningitis, in no specific order:

Strep pneumo (gram positive); group B strep (gram positive); staph aureus (gram positive); Listeria (gram positive); Neisseria meningitidis (gram neg diplococci); H flu (gram neg)

All things phenothiazines are thought to have activity against.

You’re likely to be giving patients with potential meningitis something for pain (I hope?), so why not go with compazine?  Likewise, patients whom you may suspect bacteremia from a cellulitis, why not give compazine to, ummm, “counteract the nausea” associated with the opiates you gave for pain control?

I think this falls into the unlikely to harm, might help category, and is seemingly a ripe area for research.  Is this practice changing?  Nope, not at all.  Food for thought, but until compazine is proven unsafe in an infectious process, I will continue my love affair with compazine for headaches, nausea, and vomiting (regardless of suspected etiology).

GI, Improving Outcomes, Mythbusting

Rethinking Diverticulitis

For those savvy FOAM early adopters that have been referring to diverticulitis as the sinusitis of the colon, this one is for you.

While diverticulitis management (or lack thereof) has been discussed periodically – specifically in regards to antibiotics being of no use in the uncomplicated form of diverticulitis – here comes a new study to suggest we have to at least rethink our referral patterns.

The Danish national registry was mined for a population-based cohort study, for a total of 445,456 included patients over 18 years, of whom 40,496 had a diagnosis of diverticulitis. They then compared other patients in a 1:10 ratio (diverticulitis: no diverticulitis) matched for sex and age within 1 year. Of note, the matched group also did not have a diagnosis of diverticulosis either.

Basically, the risk of developing colon cancer was 4.3% in the diverticulitis group and 2.3% in the matched cohort. This was statistically significant (P <0.001, incident ratio 1.86), and remained when adjusting for confounders (OR 2.20)…

Pro-inflammatory states cause more cancer? Perhaps. We know they cause more thromboembolism and early coronary disease already. Bottom line – while an NNT of 50 is nothing fantastic, we see this condition regularly, so reconsider providing strong follow up to your patient, whether that be PMD or GI, especially if they’re in the age where they are due for a colonoscopy anyway.

"Palliative" is not a dirty word, GI, Improving Outcomes, Improving Throughput, Mythbusting, Radiology

Versed, Pavlov, & the NGT

I admire & strive for efficiency, empathy, and efficacy.  Thus, if a certain painful procedure extends lengths of stay without significant benefit to the patient, I’m hesitant to order it. However, sometimes it is frowned upon to not play nice in the sandbox with our Pavlov consultants who request NG tubes for small bowel obstructions.



Thus, if you must place an NG tube for an obstruction, keep today’s study in mind.

Up at The U (of Vermont), patients that were ordered an NG tube and were between 18 and 60 years of age were given 1 ml of intranasal atomized co-phenylcaine (lidocaine 5% with 0.5% phenylephrine to each nostril, followed by either placebo or 2 mg of IV midazolam with NG tube placement within 5 minutes of placebo or midazolam. Using a 100 mm VAS for pain and discomfort, as the primary endpoint, the patients were interviewed 15 or 45 minutes after the procedure.

After 51 total cases (23 of which qualified for the study), the trial was stopped early as several ED clinicians felt that midazolam prior to insertion was superior to topical anesthetics alone and did not want their patients randomized in the study.

Hence, the numbers are a good bit low. Only 13 patients in the control arm, and 10 in the treatment arm. The mean difference in pain scores was 31mm and 36mm for discomfort. None of the midazolam placements were rated difficult by nursing who placed the NG tube, whereas 3/13 in the control group were rated as difficult or very difficult to place.

So yes. The numbers are small, and the authors shed some light on questions we would have. They spoke about anecdotally about 1mg of midazolam for those over 60 years old or with known pulmonary disease – which they felt did not alleviate pain or discomfort. Here, I think a 1mg bolus followed by 0.5mg boluses as needed is reasonable.

They cite a paper stating that 91% of providers would change their practice if new literature showed a convenient way to reduce patient discomfort. Well, here it is. So, if Pavlov’s dog barks and you HAVE to place an NG tube, hopefully your institutional policy allows IV midazolam without considering it procedural sedation (or, potentially using intranasal midazolam for anxiolysis).

Critical Care, GI, Improving Outcomes, Mythbusting

PPIs, ACG, and GI bleeders.

The PPI wheel is reinvented.

There is so much evidence to contradict the PPI drip, that it drives me mad that some still request a drip. We have yet another study comparing PPI bolus vs infusion for the prevention of bleeding after endoscopic submucosal dissection. Not surprisingly, as we have seen in the actively bleeding GI patient before, there was no difference in delayed bleeding or high risk ulcer stigmata with PPI bolus or drips in this study that evaluted 273 randomized patients.

Yet we continue to get push back about PPI drips. Despite this meta-analysis showing high-dose infusion for variceal hemorrhage is not beneficial, or this JAMA Internal Medicine meta-analysis  showing similar outcomes for bolus treatment vs bolus +infusion in terms of rebleeding within 3, 7, and 30 days, the need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay.  Perhaps this recent meta-analysis of 12 articles demonstrating that cirrhotic patients who use PPIs are at a higher risk of developing spontaneous bacterial peritonitis may help (OR = 2.17). While the meta-analysis looked at taking PPIs on a daily basis and future risk of developing SBP, perhaps it is not a huge stretch to suggest that an acutely ill cirrhotic GI bleeder on 8 mg per hour of your favorite PPI may be more prone to develop SBP.


So, what does the American College of Gastroenterology say?

Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg/h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death (Conditional recommendation)… After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot (Strong recommendation)…. A meta-analysis of 8 trials showed that, compared to endoscopic therapy alone (sclerotherapy or EVL), endoscopic plus pharmacological (octreotide, somatostatin, vapreotide) therapy improved the initial control of bleeding and 5-day hemostasis without differences in mortality or severe adverse events… EGD, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with EVL or sclerotherapy (Class I, Level A).

So, even ACG acknowledges that PPIs (and octreotide, while we’re at it) did not improve outcomes, yet they advocate for their use.  Important to note, they do advocate for urgent endoscopy – which they define as within 12 hours.  Next time you have to discuss a PPI drip, you can say that ACG acknowledges that it does not improve outcomes, and that high dose PPIs may predispose your sick patient to SBP.

Critical Care, GI, Improving Outcomes, Mythbusting

The Notorious N. G. T.

I’m not sure what is more appalling – that in 2010-2012, there were 386 patients who had a nasogastric tube inserted to evaluate for GI bleeding, or that it needs to be published in 2015.  I thought REBEL EM had killed off this dinosaur, but apparently not.

Fortunately, the authors come to realistic conclusions.

In this retrospective study, patients that were admitted with melena to the surgical service had an NG tube placed.  72% of them (279 of 386 patients) had a negative aspirate.  The negative predictive value of a negative aspirate?  Less than one percent. To quote the authors:

“Most patients who initially presented presented with melena and were found to have upper GI bleeding had a negative nasogastric aspirate…

Insertion of a nasogastric tube does not affect the clinical decision to perform upper endoscopy and should not be routinely carried out.”



GI, Improving Outcomes, Improving Throughput, Mythbusting

The State of the Colon Address


A history of “uncomplicated acute diverticulitis” :

– In the beginning, there was “PO therapy is equivalent to IV therapy.”

– Then, there was, “Short course of antibiotics similar to long courses of antibiotics! (4 days vs 7 days)”

– Followed by, “Antibiotics neither accelerate recovery nor prevent complications or recurrence.”

And now, some validation.

In the November 2014 issue of Scandinavian Journal of Gastroenterology, a retrospective population-based cohort study included all patients diagnosed with all types of acute colonic diverticulitis during the year 2011 at a single Swedish Hospital. 195 CT scan verified episodes of acute uncomplicated cases of diverticulitis were identified, with 178 cases not treated with antibiotics and the remaining 17 patients were treated with antibiotics. 6 patients that were not treated with antibiotics were readmitted and 2 developed an abscess (3.4% and 1.1% respectively), compared to one patient (5.9%) in the group that was treated with antibiotics and still developed an abscess. Twenty-five (12.8%) patients in the no-antibiotic group presented with a recurrence within 1 year.

Compare this to the AAFP Review on Diverticulitis, which cites an historic recurrence rate of between 9 and 36%, and what I call a 3.9% “bad bounceback rate” – meaning, they return with a perforation, abscess, or fistula. While the results from the above mentioned Journal are only from a single institute and not blinded, and having a second arm that is only comprised of 17 patients is a bit quirky- this is the second study suggesting that antibiotics do not accelerate recovery and do not prevent complications or recurrence.


And that is the State of the Colon in 2014.