Friday, March 24, 2017

Vancomycin in combination with zosyn increased the risk of AKI

Increased AKI with concomitant vancomycin and piperacillin/tazobactam should be considered when determining beta-lactam therapy.

Thursday, March 23, 2017

Type of atrial fibrillation and stroke risk

From a recent paper:

Background—Whether the pattern of atrial fibrillation (AF) modifies the risk/benefit of anticoagulation is controversial…

Conclusions—In ENGAGE AF-TIMI 48 trial, patients with paroxysmal AF suffered fewer thromboembolic events and deaths compared with those with persistent and permanent AF.

Wednesday, March 22, 2017

Hypotension due to IV acetaminophen

From a recent paper published in Critical Care Medicine:

Objectives: We sought to assess the incidence of acetaminophen-induced hypotension. Our secondary objectives were to describe systemic hemodynamic changes and factors associated with this complication.

Design: Prospective observational study.

Setting: Three ICUs.

Patients: Adult patients requiring IV acetaminophen infusion. Arterial pressure was monitored via an arterial catheter for 3 hours. Hypotension was defined as a decrease in the mean arterial pressure of greater than or equal to 15% compared with the baseline…

Conclusions: Half of the patients who received IV injections of acetaminophen developed hypotension, and up to one third of the observed episodes necessitated therapeutic intervention. Adequately powered randomized studies are needed to confirm our findings, provide an accurate estimation of the consequences of acetaminophen-induced hypotension, and assess the pathophysiologic mechanisms involved.

Tuesday, March 21, 2017

Treatment decisions for patients with a first seizure

Here is a guideline synopsis published in JAMA. From the article:

Major recommendations Whether to initiate immediate antiepileptic drug (AED) treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the adverse effects of AED therapy, a consideration of the preferences of an educated patient, and the advice that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce the risk of seizures over the subsequent 2 years…

The new guideline emphasizes that clinicians should weigh the individualized risk of seizure recurrence against the adverse effects of AEDs and consider the preferences of patients. For instance, the risk of seizure recurrence in a patient with normal electroencephalogram and brain magnetic resonance imaging results is relatively low at approximately 25% over the next 2 years.8 While some patients may accept the 25% risk, others may consider it too high. Regardless, patients should be advised that immediate treatment may not improve the long-term prognosis for seizure remission but will reduce seizure risk over the next 2 years. Despite avoiding explicit “to treat or not to treat” recommendations, most of the guideline recommendations conform to current clinical practices. States vary widely in driver licensing requirements for patients with epilepsy (, as do requirements for physicians to notify state authorities, complicating the provision of accurate instructions to patients.

Monday, March 20, 2017

Therapeutic hypothermia after in hospital cardiac arrest

There have been no RCTs looking at induced hypothermia following in hospital arrest. The 2010 ACLS guidelines recommended hypothermia for out of hospital VF/PVT arrest but only recommended that it be considered for other types of arrest. However the 2015 guidelines extended the recommendation to all post arrest comatose patients regardless of the arrest location. A new cohort study published in JAMA, drawing from a very large database, calls this into question. From the paper:

Importance Therapeutic hypothermia is used for patients following both out-of-hospital and in-hospital cardiac arrest. However, randomized trials on its efficacy for the in-hospital setting do not exist, and comparative effectiveness data are limited.

Objective To evaluate the association between therapeutic hypothermia and survival after in-hospital cardiac arrest.

Design, Setting, and Patients In this cohort study, within the national Get With the Guidelines–Resuscitation registry, 26 183 patients successfully resuscitated from an in-hospital cardiac arrest between March 1, 2002, and December 31, 2014, and either treated or not treated with hypothermia at 355 US hospitals were identified. Follow-up ended February 4, 2015.

Exposure Induction of therapeutic hypothermia.

Main Outcomes and Measures The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurological survival, defined as a Cerebral Performance Category score of 1 or 2 (ie, without severe neurological disability). Comparisons were performed using a matched propensity score analysis and examined for all cardiac arrests and separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests.

Results Overall, 1568 of 26 183 patients with in-hospital cardiac arrest (6.0%) were treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age, 61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714 non–hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1% male). After adjustment, therapeutic hypothermia was associated with lower in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to 0.97]; risk difference, −3.6% [95% CI, −6.3% to −0.9%]; P = .01), and this association was similar (interaction P = .74) for nonshockable cardiac arrest rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference, −3.2% [95% CI, −6.2% to −0.3%]) and shockable cardiac arrest rhythms (41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, −4.6% [95% CI, −10.9% to 1.7%]). Therapeutic hypothermia was also associated with lower rates of favorable neurological survival for the overall cohort (hypothermia-treated group, 17.0% [246 of 1443 patients]; non–hypothermia-treated group, 20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, −4.4% [95% CI, −6.8% to −2.0%]; P less than  .001) and for both rhythm types (interaction P = .88).

Conclusions and Relevance Among patients with in-hospital cardiac arrest, use of therapeutic hypothermia compared with usual care was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of favorable neurological survival. These observational findings warrant a randomized clinical trial to assess efficacy of therapeutic hypothermia for in-hospital cardiac arrest.

The ACLS guidelines now have a dynamic (continuously updating) web page but this study has yet to be mentioned there.

Sunday, March 19, 2017

The patient safety movement: how are we doing?

According to the authors of a recent viewpoint article in JAMA, although the decade following the Institute of Medicine Report was widely regarded as a failure, progress may have been made from 2000 to 2014. The data are a little soft, though and it is difficult to tell whether the purported improvement is due to systems improvements, secular trends or pervasive chart doctoring which is believed to have increased over the past few years with the recent external pressures.