Sunday, February 26, 2017

Dexmedetomidine for agitated patients on mechanical ventilation


From a recent study:

Importance Effective therapy has not been established for patients with agitated delirium receiving mechanical ventilation.

Objective To determine the effectiveness of dexmedetomidine when added to standard care in patients with agitated delirium receiving mechanical ventilation.

Design, Setting, and Participants The Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial involving 74 adult patients in whom extubation was considered inappropriate because of the severity of agitation and delirium. The study was conducted at 15 intensive care units in Australia and New Zealand from May 2011 until December 2013. Patients with advanced dementia or traumatic brain injury were excluded.

Interventions Bedside nursing staff administered dexmedetomidine (or placebo) initially at a rate of 0.5 µg/kg/h and then titrated to rates between 0 and 1.5 µg/kg/h to achieve physician-prescribed sedation goals. The study drug or placebo was continued until no longer required or up to 7 days. All other care was at the discretion of the treating physician.

Main Outcomes and Measures Ventilator-free hours in the 7 days following randomization. There were 21 reported secondary outcomes that were defined a priori.

Results Of the 74 randomized patients (median age, 57 years; 18 [24%] women), 2 withdrew consent later and 1 was found to have been randomized incorrectly, leaving 39 patients in the dexmedetomidine group and 32 patients in the placebo group for analysis. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo (median, 144.8 hours vs 127.5 hours, respectively; median difference between groups, 17.0 hours [95% CI, 4.0 to 33.2 hours]; P = .01). Among the 21 a priori secondary outcomes, none were significantly worse with dexmedetomidine, and several showed statistically significant benefit, including reduced time to extubation (median, 21.9 hours vs 44.3 hours with placebo; median difference between groups, 19.5 hours [95% CI, 5.3 to 31.1 hours]; P less than .001) and accelerated resolution of delirium (median, 23.3 hours vs 40.0 hours; median difference between groups, 16.0 hours [95% CI, 3.0 to 28.0 hours]; P = .01). Using hierarchical Cox modeling to adjust for imbalanced baseline characteristics, allocation to dexmedetomidine was significantly associated with earlier extubation (hazard ratio, 0.47 [95% CI, 0.27-0.82]; P = .007).

Conclusions and Relevance Among patients with agitated delirium receiving mechanical ventilation in the intensive care unit, the addition of dexmedetomidine to standard care compared with standard care alone (placebo) resulted in more ventilator-free hours at 7 days. The findings support the use of dexmedetomidine in patients such as these.



Saturday, February 25, 2017

Impact of a post-arrest consult team


From a recent study:

Objective: To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest.

Design: Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others.

Setting: Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada.

Patients: We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management.

Intervention: The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication.

Measurements and Main Results: We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02–0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31–2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17–21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11–8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19–2.94).

Conclusions: Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.

This is an appealing idea to me. Although the consult team did not have much impact in this study I believe it is an idea worth considering which may be of value in some institutions when used for all it is worth.

Friday, February 24, 2017

Point of care echo and diastolic dysfunction


In this study emergency physicians were competent in the identification of diastolic dysfunction after limited training but not in the classification of DD.

Thursday, February 23, 2017

Point of care chest ultrasound


Here is a review of its usefulness as a clinical tool, excluding cardiac applications.

Wednesday, February 22, 2017

Pnuemonia in comatose patients post cardiac arrest


75% of patients developed pneumonia!


Methods: We identified consecutive patients undergoing targeted temperature management following OHCA secondary to a shockable rhythm (ventricular tachycardia or fibrillation). To address survival bias we excluded patients who died within 48 hours of hospital admission. We then compared clinical outcomes between patients with and without pneumonia. The primary outcome was severe neurologic dysfunction as defined by a cerebral performance category (CPC) ≥3; secondary outcomes included duration of mechanical ventilation and length of stay in hospital and in the cardiac intensive care unit (CICU).

Results: Of 116 patients included (mean age 57 years, mean downtime 24 min, 22% female, 47% STEMI), 87 (75%) developed pneumonia. Patients who developed pneumonia were older; baseline patient and index event characteristics were otherwise comparable between the two cohorts. The most common pathogens isolated included Staphylococcus aureus, Haemophilus influenza, Streptococcal species and Klebsiella species. Piperacillin/tazobactam and cephalosporins were used to treat the majority of patients. The incidence of the primary outcome (28%) was comparable in patients with versus without pneumonia. However, compared to patients without pneumonia, OHCA patients with pneumonia required longer periods of mechanical ventilation and longer lengths of stay in hospital and in the CICU.

Tuesday, February 21, 2017

Your GI bleeding patient is on antiplatelet therapy. Should you transfuse platelets?


From a recent retrospective cohort study:

Background & Aims

Antiplatelet agents decrease cardiovascular events but increase gastrointestinal bleeding (GIB). Guidelines propose platelet transfusion for patients who take antiplatelet agents and have serious GIB. We investigated whether such patients are at decreased risk for rebleeding or increased risk for cardiovascular events after platelet transfusion.

Methods

We performed a retrospective cohort study of patients with GIB admitted to Yale-New Haven Hospital from 2008 to 2013 who were taking antiplatelet agents and had platelet counts higher than 100 × 109/L. Cases (patients who received platelet transfusion, n = 204) were matched with controls (no platelet transfusions, n = 204) for sex, age, and GIB location. The primary outcome was recurrent GIB. Multivariable regression analyses were performed to adjust for differences in baseline characteristics.

Results

Cases and controls had similar proportions of GIB due to non-variceal upper GIB (117 of 204, 57% vs 115 of 204, 56%) and colonic GIB (80 of 204, 39% vs 81 of 204, 40%). Cases had more severe GIB than controls, which was based on lower blood pressure and hemoglobin levels and higher heart rates and the proportion admitted to intensive care. Univariate analyses showed that higher proportions of cases had major cardiovascular events (23% vs 13% for controls), died (7% vs 1% for controls), or had hospital stay longer than 4 days (47% vs 33% for controls). However, multivariable analyses showed a significant difference between cases and controls in only risk of death (odds ratio, 5.57; 95% confidence interval, 1.52–27.1). The adjusted odds ratio for recurrent bleeding was 1.47 (95% confidence interval, 0.73–3.05) for cases vs controls.

Conclusions

The use of platelet transfusions in patients with GIB who are taking antiplatelet agents without thrombocytopenia did not reduce rebleeding but was associated with higher mortality. At least some of the increase in mortality could be due to the residual bias of an observational study, but because of the lack of benefit, we do not support the use of platelet transfusions in patients with GIB who are taking antiplatelet agents.