Critical Care

Who ya gonna call? #VancZosyn!

If there’s some strange cough in your resus room,

Who you gonna call? Vanc-ZoSyn!
If something’s fevered… and it don’t look good,
Who you gonna call? Vanc-ZoSyn!

I ain’t afraid of no Staph.
I ain’t afraid of no Strep.

If high lactates are running through your EMR,
Who you gonna call? Vanc-ZoSyn!

 

There’s been some FOAM rumblings about Vanc/ZoSyn causing AKI, but this was the first time it has been compared directly head to head with Vancomycin-Cefepime. This was a retrospective matched cohort study with 279 patients in each arm – one received combination therapy with vancomycin-cefepime (VC), the other received vancomycin-piptazobactam (VPT) for > 48 hours. Patients were excluded if their baseline serum creatinine was >1.2mg/dl or they were receiving RRT. Patients receiving VC were matched to patients receiving VPT based on severity of illness, ICU status, duration of combination therapy, vancomycin dose and number of concomitant nephrotoxins. The primary outcome was the incidence of RIFLE criteria-defined AKI, with a slew of secondary outcomes performed as well.

So, wait, what’s so special about RIFLE anyway? Glad you asked: In general, the worse the acute kidney injury, the higher the mortality.

Since this study shows an 11% AKI rate with VC and 29% AKI rate with VPT, maybe we can improve our mortality if we simply switch from zosyn to cefepime?

Except that this group reports mortality was actually worse in the VC group (though not statistically significant – 8.6% vs 5.7%). That’s right – the group with more AKI had less mortality. In other news, ICU stay was decreased (6 vs 8 days), which was statistically significant., and only ~1% of patients in both arms required long term hemodialysis.

While I was getting ready to click submit on this blog post, I found a second paper (published Nov 28, 2016) that looked at a matched cohort of 1633 VPT vs 578 VC patients, with essentially similar results – 21.4% AKI in VPT vs 12.5% VC.  This second paper found similar LoS, but also a similar trend in mortality-  6.9% for the VPT arm and 9.2 for VC.

So… I’m not certain what to make of this – but it seems more than fair to question whether drug induced AKI is a meaningful surrogate marker for sepsis mortality.  We need a long term look at mortality between VC vs VPT to see if VPT induced AKI follows the same trends. Maybe we’re trading a slight bump short term mortality for improved long term mortality with VC (or maybe not).  In the meantime, I think we need to pump the brakes on shouting about Vanc/Zosyn AKI until we sort this out a bit more.

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Critical Care, Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics, Pulmonary

Do we need to give (alot) more Magnesium to asthmatics?

Some of us have quirky things we like to do that not everyone else does– dexamethasone for sore throats, ketamine for the agitated patient (or anything really), et cetera… This paper looks at one of those things – Magnesium in asthmatics. 

This was a prospective, randomized open-label study of patients between 6 and 18 years of age over a two year period who presented to an ED in Asuncion, Paraguay and were admitted for a severe asthma exacerbation.  Patients were excluded if given antibiotics before or during the ED visit, febrile, or if there was suspicion for infectious etiology.  All patients enrolled had no relief despite 2 hours of treatment which included dexamethasone 0.2mg/kg IV, nebulized salbutamol every 20 minutes up to 5mg and nebulized albuterol every 2 hours.  There were two treatment arms, each with 19 patients: one received a 50mg/kg bolus of MgSO4, while the other group received 50mg/kg/hr/4 hrs (ie, up to 2g / hr for 4 hours – up to 8g total).  Physicians in charge of patient disposition, after the initial 8 hours, were not part of the study group and blinded to the treatment received.  Primary outcome was discharge at 24 hours, with secondary outcomes total LOS and cost implications.  The two groups were similar in terms of age, sex, initial Wood-Downes asthma score, and peak flows.

Despite the numerous downfalls to this study (single center, open-label, prospective, small sample size…), the results are intriguing- bolus magnesium had an average LOS of 48 hours vs 34 hours for high dose prolonged infusions, had a higher cost ($834 vs $603), and fewer patients with a LOS <24 hrs (10.5% vs 47.4%).  It took almost two years to get under 40 patients in this single-center study,  but still, there were no adverse events and no bounceback visits within a week from discharge.  Interestingly, there were no obese patients in the study – so how applicable this study is to the US patient population, I do not know (plus, salbutamol is not widely used for acute asthma in the US).   That, and even for this mag-o-phile 8g per hour for 4 hours seems like alot!

Should this change your practice?  Not quite yet – unless you’re not giving magnesium.  In the meantime, I’ll add another one to the list of trials I’d love to see.

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Cardiology, Cardiology, Improving Outcomes, Improving Throughput, Mythbusting

Chest Pain Statistics That’ll Make Obs Bump Trops

I have been lucky enough to attend ACEP over the last few years, and even luckier to watch David Newman speak. Specifically, I have attended his “Is One Troponin Enough?” lecture, which was practice changing for me.  It also encouraged me to drench both my patient discussions and MDM’s in evidence prior to discharging patients. Among others, Newman is at it again in today’s article, found here.

At 3 institutions over 5 years, from July 1, 2008 to June 30, 2013, encompassing over a million ED visits in total at these three institutions combined, the authors sought to determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with two negative troponins, normal vital signs at time of arrival to the ED, and nonischemic EKGs throughout their stay.  Clinically relevant events were defined as life-threatening arrythmia, inpatient STEMI, cardiac or respiratory arrest, or death during hospitalization.

Essentially, during the 5 year study period, over one million ED visits, and over 11,000 patients admitted with two negative troponins, only 20 patients had an adverse outcome (0.18%). When you exclude abnormal vitals at presentation, ischemic EKG findings, left bundle branch block or a paced rhythm, only 4 events were seen out of 7266 patients (0.06%), with two being non-cardiac, and two (possibly) being iatrogenic.

Wow.

Let’s process this for a minute.  When taking all-comers – not just the low risk observation patient- with two negative troponins (drawn between 60-240 minutes in this study) your risk is quite low at 0.18%, now exclude non-ischemic EKGs, patients with abnormal vitals, a paced rhythm, or a left bundle branch block, and your risk is 0.06% of an adverse outcome – and more likely to be iatrogenic than cardiac!

Now let’s couple the above study with this study, where they examined almost 700,000 private-insurance ED patients in 2011 presenting with chest pain. They followed patients that both did and did not receive additional diagnostic testing (exercise stress test, stress ECHO, myocardial perfusion scintigraphy, or coronary CTA). Essentially, the rate of MI at 7 days and 190 days was low overall (0.11% and 0.33% respectively). Most importantly – patients who did not undergo initial non-invasive testing were no more likely to experience a myocardial infarction than those who did not receive additional testing. Compared to no testing, additional testing was associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.

So why are we consulting cardiology for observation patients with two negative troponins? Why are we ordering stress testing for inpatient or observation patients? This is yet another example of why it is important to provide well-informed consent for your patient, and a great example of a well-intentioned hospitalization and consultation providing (potentially) more harm than good.

It is high time we cease and desist the scare tactics we employ to patients to strong arm them into either an AMA or admission, rather than providing them a look at the current data before making their decision.

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Improving Outcomes, Improving Throughput, Mythbusting, Pediatrics

The Bell Tolls for the PICC

In today’s fight against “this patient needs IV antibiotics,” this study looks at 2060 children hospitalized for osteomyelitis from January 1, 2009, through December 31, 2012, at 36 participating children’s hospitals. 1055 received a PICC line at discharge for IV antibiotics, 1005 received oral antibiotics only at time of discharge. Among the children in the PICC group, 158 (15.0%) had a PICC complication, with 5.9% of all PICC patients requiring a rehospitalization – rates much worse than the PO antibiotic group.

Sure, I guess PICCs are great for patients allergic to many oral antibiotics, but they represent a select group. There is evidence that early oral antibiotics are better for acute cholangitis and bacteremia, and early conversion to PO antibiotics reduces length of stay without causing harm. Then there is the dogma of needing IV antibiotics for the pregnant pyelonephritis patient and orbital cellulitis, not to mention the fact that even a single dose of IV antibiotics is associated with more AAD.

When you take into account the amount of time off work for the patient and family, the associated cost of an infusion center and visiting nursing services, and consider that the evidence generally guides away from the usage of IV antibiotics when PO options are available, its time to toll the bell for routine placement of PICCs.

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Improving Outcomes, Improving Throughput, Mythbusting

Steroids, Cellulitis, and the IV Antibiotics Hoax.

There’s been a rash of literature on steroids for infectious processes, and today’s post is no different. At the end of 2014, a study came out looking at 31 pediatric patients at a tertiary children’s hospital diagnosed with orbital cellulitis that were evaluated for the efficacy of adjuvant steroids.  All patients were initially treated with IV antibiotics and surgical decompression was performed as indicated by previously published criteria, regardless of treatment arm.  CRP was measured daily, and when it was below 4 mg/dl, 1 mg/kg of oral prednisone once daily for 7 days was initiated.

 

Admittedly, the numbers are small – only 24 patients received steroids while only 7 did not.  More patients in the steroid group underwent surgery before prednisone initiation (13/24, 54% vs 2/7, 29%).  Likewise, patients in the steroid treatment arm had a shorter length of stay after initiation of steroids (1.1 days vs 4.9 days), and had less time overall in the hospital (3.96 days vs 7.17 days) with one case of recurrence in both treatment arms, and no cases of vision loss or permanent ocular disability in either group.

 

Why wait for a number to tell you to start treating with steroids when this trial of 21 patients initiated oral steroids after an initial clinical response to IV antibiotics.  The steroid treated arm had better visual acuity, decreased residual ptosis, proptosis, and improved extracoular movements compared to those not treated with steroids with a significantly decreased length of stay and decreased duration of IV antibiotics.

 

Better yet, why start IV antibiotics? Or at least why not rapidly transition the patient to oral antibiotics?  This trial of 19 patients with orbital cellulitis started empirically on oral ciprofloxacin and oral clindamycin showed no difference between oral and IV therapy.  Again, small numbers, emerging trend.  Previous trials have shown oral antibiotics as sole treatment to be effective for high risk cases such as neutropenic fever, endocarditis and osteomyelitis.  The thought of “needing to stay for IV antibiotics” when an equivalent and efficacious oral alternative exists is downright silly – not to mention associated costs for the patient without an improvement in their care.

 

Don’t want to start steroids?  Well at least consider NSAIDs- where this trial showed that 83% of patients treated with 400mg of ibuprofen every 6 hours had regression of inflammation at 1-2 days vs only 9% of those treated without NSAIDs.  There is little reason aside from being allergic to everything not named vancomycin to start IV antibiotics for most infectious processes.

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Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 11 of Christmas: Telepsychiatry For All!

Welcome to the Twelve Trials of Christmas series on EMinFocus!  This is the eleventh of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM.  Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

This is not so much a trial as something that needs to be done.  For anyone that works at an ED that has a psychiatry unit, you have likely seen wait times in excess of 24 hours regularly “waiting for a bed.” You’ve likely not checked in on that dispositioned psych hold all shift as well.  All of this creates an unsafe environment for patients both of psych and non-psych ilk, and to some extent, ED staff.

Enter, telepsychiatry.  This has actually been piloted, and found the agreement between the psychiatrists about disposition with a face-to-face assessment was 84% vs 86% with telemedicine.  There were no significant differences for disposition recommendation, strength of recommendation, diagnosis, the HCR-20 dangerousness scale, or suicide scale.

Telepsychiatry has been used in critical access hospitals, demonstrating mean and median times to consult were reduced from 16 hours and 14 hours respectively, to 5.4 hours 2.5 hours, with similar reductions in length of stay and door-to-consult times.

We could set up a tiered system of having a crisis counselor do the intake, much like we usually do, followed by immediate psychiatry evaluation, rather than holding them in the ED until the morning to see the patient.  We could also immediately initiate medication on the patient to decrease their LOS as an inpatient.  With residency fill rates approaching 100% (98, 99, and 96% in the last 3 years – better than anesthesia or radiology!), and with more total positions than orthopaedics, neurology, dermatology, radiology, or ob-gyn, we could easily decrease ED wait times for psych eval, and likely decrease LOS as an inpatient by, conservatively, 12 hours if we could start them on meds in the ED.

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