Critical Care, Improving Outcomes, Mythbusting

1 in 10 EGLS saves a life.

Do current sepsis guidelines go far enough?

That was my first thought when I read today’s article. This single center ICU study looked at 220 patients divided into two categories- one category in which patients that were managed in adherence with the 2012 surviving sepsis guidelines – 20-49 ml / kg initial IV fluid bolus, continued fluid challenges until CVP of 8-12, with more given based on treating team. Noradrenaline until MAP of 65, and dobutamine for cvSO2 <70% in combination with either lactate >2 or urine output <0.5 ml / kg / hr). The other 110 patients had treatment guided by limited echo:

Treatment options looked like this:

1) IVC fluctuation <15% & normal LV function= give pressors only (discontinue IV fluid)

2) IVC fluctuation >15% & normal LV function = 20-40 ml /kg IV fluid given

3) IVC fluctuation >15% & mod/severe LV function = 10-20ml/kg IV fluid given AND initiate dobutamine 5ug/kg/min

4) IVC fluctuation <15% & mod/severe LV function = discontinue IV fluid and initiate dobutamine 5 ug/kg/min

 

These patients were pretty sick- all patients were mechanically ventilated and on noradrenaline. Limited echo was performed within 24 hours of presentation to ICU and within 36 hours of presentation to the ED (actual times were within 7-15 hours in the ICU, on average, 11 hours). Patient characteristics were pretty similar in terms of age, APACHE scores, and labs (similar ESRD/CHF percentage as well ~20% of both patient arms). Surprisingly, patients received a ridiculous amount of IV fluid from the ED – 68 (55-70) ml / kg in the echo group vs 65 (55-72) ml / kg in the standard of care arm. Yes, even with 20% of patients having ESRD / CHF – the least amount of IVF given was 55 ml / kg !

Results?

Despite all of this IV fluid given in the ED, 35% of patients still have >15% IVC collapse (!). 65% of patients had their fluid restricted, and 22% in the echo arm vs 12% in the standard of care were started on dobutamine. On Day 1 in the ICU, patients received less IVF in the echo arm (49 (33-74) ml / kg, vs 66 (42=100) ml / kg) – but still a significant amount if IVF.

28 day survival was 56% vs 66% in favor of the echo arm, with significantly less acute kidney injury (65% vs 88% for all AKI, and 19% vs 36% for stage 3 AKI).

So your NNT to save a life is 10, and 4 to reduce incidence of any AKI.

So, is this really an ED paper? Well, it depends on your area of practice. The local flavor of the authors is such that their local policy was to initiate dobutamine in the ICU and not in the ED. Are you boarding ICU players? Are your hospitalists ultrasono savvy? How involved are your intensivists in patient care while patients are awaiting an ICU bed? Are you okay with administering at least 40 ml /kg IV fluid and starting pressors on your septic shock patients? If the answer is no or “not really” to any of these questions, then the answer is yes.

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Improving Throughput, Mythbusting, Radiology, Radiology

Sono-guided Right IJ? Skip the chest film.

1,322 sono guided IJ central lines. Guess how many pneumothoraces.

One. Exactly one.

Overall success rate – 96.9%.

One percent of the time the catheter required repositioning. So, basically a failed rate of 2%.

Zero arterial placements.

Sure, 1,322 over a one year period is insanity (Henry Ford in Detroit, if you’re curious), and you can easily argue that a hospital that places that many central lines probably has it down cold.

Bottom line, if you are competent enough to place an ultrasound guided right sided IJ central line, you can skip the xray, especially if it is going to delay care. You do not image your femoral lines before usage, do you?

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Cardiology, Critical Care, Improving Outcomes, Improving Throughput, Radiology

POCUS, Aneurysms, and Mortality Rates.

If you’re a #FOAM follower, you have probably seen the pleas for bedside ultrasound more than once. This paper takes an interesting approach to try and demonstrate its value in the diagnosis of aortic dissection: Over a two year period and 386,547 patient visits, there was a review of 123 medical reports and 194 autopsy reports, of which 32 patients were identified for inclusion. 16 received EP POCUS, 16 did not.

Median time to diagnosis – 80 minutes in the POCUS group vs 226 minutes in the non POCUS group. Misdiagnosis was 0% in the POCUS.

Mortality adjusted for DNR status: 15.4% vs 37.5%, POCUS vs non-POCUS.

Time to dispo? 134 minutes vs 205 minutes, POCUS vs non-POCUS. (and probably a much greater difference in time to *appropriate* disposition.)

[note that neither mortality or time to dispo was statistically significant] 

With that said, I agree with the authors conclusions, (particularly in light of this previous post): “Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.”

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Mythbusting

Peds, POCUS, & SSTI.

Generally, most pediatric patients I’ve seen despise “needles.” Fortunately, they general love ipads and various other forms of technology. This particular study combines the two. Looking at 151 skin & soft tissue infections among 148 patients, the initial treating physician recorded their initial assessment as to whether or not there was a drainable collection, which was followed by a second physician who was blinded to the first assessment, doing an ultrasound.

In the above referenced study, POCUS for an abscess had a sensitivity of 95% and specificity of 87%. Physical exam sensitivity was 84% with 60% specificity. Add in this lit review – which also shows a higher sensitivity for US, and – especially for peds who run and scream at the suggestion of an I&D – there is no reason to not be doing more POCUS in these situations.

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Improving Outcomes, Improving Throughput

Dont hang your CAP on that Xray!

What is your threshold for sensitivity of a test? If head CT missed 30% of bleeds, would we even do them? If UA’s missed 30% of UTI’s, would we even send them for anything other than culture? Would you feel comfortable making a decision based off a test that misses 30% of an infectious process that is common in your ED?

Here, 319 prospectively enrolled patients with suspected community acquired pneumonia were subjected to plain films and followed by Chest CT. CT revealed an infiltrate in a third of patients who did not have an infiltrate on chest film and excluded CAP in 29.8% of patients with an infiltrate on chest film. 6.9% of patients were hospitalized (rather than discharged), and 7.2% were discharged rather than admitted based off CT findings (22 vs 23 patients).

The authors suggest that changing the disposition on 14% of patients is worth the “just scan ’em” mentality, while I would argue that a better question would be, why waste everyone’s time when you could just pull out the ultrasound? (Not to mention you would have an answer faster, at ~95% sensitivity?)

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Improving Outcomes, Improving Throughput, Pediatrics, Pediatrics

Increased sono, decreased negative peds appy rate.

Academia and community ED settings are very different, and sometimes one community to the next is often times very different as well. This study– which included 35 pediatric ED’s and 52,000+ cases of appendicitis demonstrates this. Essentially, the authors took all their appendicitis data from 2010-2013, and looked at what imaging, if any, the patient received, negative appendectomy rates, length of stay, frequency of perforation, and 3 day bounceback rates from initial ED visit (ie, did ultrasound or CT “miss” an eventual appendicitis?)

Ultrasound use increased from 24% in 2010 to 35.3% in 2013 for the sole diagnostic modality in what eventually was diagnosed as appendicitis. CT rate decreased 21.4% in 2010 to 11.6% in 2013. Almost 50% of the patients (25,254 out of 52,153) had neither CT or US (!). The negative appendectomy rate in 2010 was 4.7%, while in 2013, it was 3.6%. There was no difference in length of stay, frequency of perforation, or 3 day bounce back rates from 2010 to 2013.

Ok. If you work in a community ED, raise your hand if 50% of your potential appendicitis cases get seen by surgery without any imaging. Only 11.6 % CT use? I think most community surgeons would be less than thrilled to be called at 2am for a “rule out” appendicitis evaluation without imaging.

While I think the authors live in an alternate universe, I think this paper makes a great argument to do the right thing. It would be great if non-academic settings could utilize US and surgical consultations for a “hot belly” without shipping them off to radiology. Or better yet, have surgery perform POCUS with you to confirm findings.

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Critical Care, Improving Outcomes, Mythbusting

POCUS in codes: Is that PEA really PEA?

So a few weeks ago, I asked the Twittersphere whether or not ultrasound should be readily available (if not outright used) in all codes.  The answer was a resounding yes, and today’s article helps support that claim.

49 ICU patients with cardiopulmonary arrest (asystole or PEA) underwent intra-arrest bedside TTE.  Based on Echo findings, these patients were classified as either asystole, PEA without cardiac contractility, or PEA with cardiac contractility.  ROSC and survival to discharge, and survival to 180 days were evaluated. Of these 49 patients, 17 (35%) were in asystole based on Echo, 5 (10%) were in PEA without cardiac contractility, and 27 (55%) were in PEA with cardiac contractility.  Rates of ROSC were 23.5% for those in asystole, 20% for PEA without cardiac contractility, and 70.4% for those in PEA with cardiac contractility.  Survival to discharge (22%) and after 180 days (15%) only occurred in the PEA group with cardiac contractility.  (Full disclosure- no word on CPC neurologic outcomes for survivors).

Now, this study looks at ICU arrests – clearly a bit different from OHCA cases we see in the ED, and perhaps intrigues me to suggest using cardiac POCUS in OHCA to stratify the futility of the resuscitation (This review found significant bias and large heterogeneity for prehospital sono usage for arrests).  Nevertheless, with 15% 6-month survival in a group that without bedside sono you would call the code – its time to seriously consider the use of ultrasound (at least for) cardiac evaluation in all codes.  For all of the things we do that fall into the “can’t hurt, might help” category, ultrasound in an arrest has to be high on the list.

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