Friday, March 22, 2019

A virtual museum of mechanical ventilators

Interesting stuff here.

Using ventilator graphics

Medical decision making for unbefriended older adults: an AGS position statement

Policy Recommendations

1.National stakeholders should work together to create legal standards regarding unbefriended older adults that could be considered for adoption by all states.
2.Clinicians, health care organizations, and other stakeholders should work proactively to prevent older adults without potential surrogates from becoming unbefriended.
3.Clinicians, health care organizations, communities, and other stakeholders should develop innovative, efficient and accessible approaches to promote adequate protections and procedural fairness in decision making for unbefriended older adults.

Clinical Practice Recommendations

4.Medical decision making for unbefriended older adults should include adequate safeguards against ad hoc approaches and ensure procedural fairness.
5.Clinicians should consider non-traditional surrogate decision makers for unbefriended older adults.
6.Clinicians should assess medical decision-making capacity in a systematic fashion.
7.Clinicians and healthcare institutions should develop and standardize/systematize methods to make decisions for unbefriended older adults in urgent, life-threatening situations.
8.Clinicians and healthcare institutions should ensure that patients with long-term incapacity have longitudinal access to a decision-making surrogate who is familiar with the patient's medical condition and specific circumstances.
9.When applying the best interest standard to unbefriended older adults, institutional committees (such as an ethics committee) should synthesize all available evidence, including cultural and ethnic factors, during deliberations about treatment decisions.

Thursday, March 21, 2019

Diagnosis of upper extremity DVT


•The evidence on the diagnostic management of upper extremity deep vein thrombosis is scarce.
•Only one study evaluated the use of a diagnostic algorithm, similar to the one used for deep vein thrombosis of the lower extremities.
•Further studies are needed to validate the algorithm, especially in high-risk subgroups.


Upper extremity deep vein thrombosis (UEDVT) accounts for 4% to 10% of all cases of deep vein thrombosis. UEDVT may present with localized pain, erythema, and swelling of the arm, but may also be detected incidentally by diagnostic imaging tests performed for other reasons. Prompt and accurate diagnosis is crucial to prevent pulmonary embolism and long-term complications as the post-thrombotic syndrome of the arm. Unlike the diagnostic management of deep vein thrombosis (DVT) of the lower extremities, which is well established, the work-up of patients with clinically suspected UEDVT remains uncertain with limited evidence from studies of small size and poor methodological quality. Currently, only one prospective study evaluated the use of an algorithm, similar to the one used for DVT of the lower extremities, for the diagnostic workup of clinically suspected UEDVT. The algorithm combined clinical probability assessment, D-dimer testing and ultrasonography and appeared to safely and effectively exclude UEDVT. However, before recommending its use in routine clinical practice, external validation of this strategy and improvements of the efficiency are needed, especially in high-risk subgroups in whom the performance of the algorithm appeared to be suboptimal, such as hospitalized or cancer patients.

In this review, we critically assess the accuracy and efficacy of current diagnostic tools and provide clinical guidance for the diagnostic management of clinically suspected UEDVT.

Systematic review and meta-analysis of tygecycline in bloodstream infections

This paper is complex but seems to show that tygecycline is best in combination therapy .

Topiramate renal toxicity

Troponin elevation in stroke: what does it mean?

Background and Purpose—Acute ischemic stroke (AIS) patients may have raised serum cardiac troponin levels on admission, although it is unclear what prognostic implications this has, and whether elevated levels are associated with cardiac causes of stroke or structural cardiac disease as seen on echocardiogram. We investigated the positivity of cardiac troponin and echocardiogram testing within a large biracial AIS population and any association with poststroke mortality.

Methods—Within a catchment area of 1.3 million, we screened emergency department admissions from 2010 using International Classification of Diseases, Ninth Edition, discharge codes 430 to 436 and ascertained all physician-confirmed AIS cases by retrospective chart review. Hypertroponinemia was defined as elevation in cardiac troponin above the standard 99th percentile. Multiple logistic regression was performed, controlling for stroke severity, history of cardiac disease, and all other stroke risk factors.

Results—Of 1999 AIS cases, 1706 (85.3%) had a cardiac troponin drawn and 1590 (79.5%) had echocardiograms. Hypertroponinemia occurred in 353 of 1706 (20.7%) and 160 of 1590 (10.1%) had echocardiogram findings of interest. Among 1377 who had both tests performed, hypertroponinemia was independently associated with echocardiogram findings (odds ratio, 2.9; 95% confidence interval, 2–4.2). When concurrent myocardial infarctions (3.5%) were excluded, hypertroponinemia was also associated with increased mortality at 1 year (35%; odds ratio, 3.45; 95% confidence interval, 2.1–5.6) and 3 years (60%; odds ratio, 2.91; 95% confidence interval, 2.06–4.11).

Conclusions—Hypertroponinemia in the context of AIS without concurrent myocardial infarction was associated with structural cardiac disease and long-term mortality. Prospective studies are needed to determine whether further cardiac evaluation might improve the long-term mortality rates seen in this group.

Thrombolytic versus conventional therapy for submassive PE

Wednesday, March 20, 2019

Syncope review

What to do with subclinical hyperthyroidism

From a recent concise review:

Subclinical hyperthyroidism is defined by a low or undetectable serum thyroid-stimulating hormone level, with normal free thyroxine and total or free triiodothyronine levels. It can be caused by increased endogenous production of thyroid hormone (e.g., in Graves disease, toxic nodular goiter, or transient thyroiditis), by administration of thyroid hormone to treat malignant thyroid disease, or by unintentional excessive replacement therapy. The prevalence of subclinical hyperthyroidism in the general population is about 1% to 2%; however, it may be higher in iodine-deficient areas. The rate of progression to overt hyperthyroidism is higher in persons with thyroid-stimulating hormone levels less than 0.1 mIU per L than in persons with low but detectable thyroid-stimulating hormone levels. Subclinical hyperthyroidism is associated with an increased risk of atrial fibrillation and heart failure in older adults, increased cardiovascular and all-cause mortality, and decreased bone mineral density and increased bone fracture risk in postmenopausal women. However, the effectiveness of treatment in preventing these conditions is unclear. A possible association between subclinical hyperthyroidism and quality-of-life parameters and cognition is controversial. The U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for thyroid dysfunction in asymptomatic persons. The American Thyroid Association and the American Association of Clinical Endocrinologists recommend treating patients with thyroid-stimulating hormone levels less than 0.1 mIU per L if they are older than 65 years or have comorbidities such as heart disease or osteoporosis.

Increased risk of stroke after an episode of sepsis

Background and Purpose—Infections have been found to increase the risk of stroke over the short term. We hypothesized that stroke risk would be highest shortly after a sepsis hospitalization, but that the risk would decrease, yet remain up to 1 year after sepsis.

Methods—This case-crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project. All stroke admissions were included. Exposure was defined as hospitalization for sepsis or septicemia 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between sepsis/septicemia and ischemic or hemorrhagic stroke.

Results—Ischemic (n=37 377) and hemorrhagic (n=12 817) strokes that occurred in 2009 were extracted where 3188 (8.5%) ischemic and 1101 (8.6%) hemorrhagic stroke patients had sepsis. Sepsis within 15 days before the stroke placed patients at the highest risk of ischemic (OR, 28.36; 95% CI, 20.02–40.10) and hemorrhagic stroke (OR, 12.10; 95% CI, 7.54–19.42); however, although the risk decreased, it remained elevated 181 to 365 days after sepsis for ischemic (OR, 2.59; 95% CI, 2.20–3.06) and hemorrhagic (OR, 3.92; 95% CI 3.29–4.69) strokes. There was an interaction with age (P=0.0006); risk of developing an ischemic stroke within 180 days of hospitalization for sepsis increased 18% with each 10-year decrease in age.

Conclusions—Risk of stroke is high after sepsis, and this risk persists for up to a year. Younger sepsis patients have a particularly increased risk of stroke after sepsis.

Stressed volume in critical care

Tuesday, March 19, 2019

Get those discharge summaries out. Faster please.

Single dose dexamethasone almost as affective as a five day prednisone regimen in acute asthma

A single dose of 12-mg dexamethasone, which has a longer duration of action than prednisone, is almost as effective as five days of 60-mg prednisone for the prevention of relapse in adults with acute asthma treated in an emergency department. It is a reasonable option for treatment in the emergency department, given its fewer adverse effects. In this study, patients who received the single dose also took placebo for four days. Further research is needed to determine whether patients are comfortable with taking just a single dose. (Level of Evidence = 2b)

The strong ion difference in predicting the severity of acute pancreatitis


In a cohort of patients with AP, SIG was a strong independent predictor of severity and mortality. Besides, SIG might also be an early marker for acute kidney injury in AP patients. Additional research is needed to identify the nature of the unmeasured anions responsible for such findings.

Monday, March 18, 2019

Chronic tachycardia induced cardiomyopathy

An update on this topic recently appeared in JACC.

First a little background. This was the topic of one of my very first blog posts almost 12 years ago.

Decades ago this entity was described in patients with incessant forms of SVT (eg long RP or “fast-slow reentry” tachycardias. Some of these were also ectopic atrial tachycardias). These patients had heart failure with low ejection fractions and some were cured after ablation. (See here). It wasn’t until much later when it was recognized that this entity could result from longstanding uncontrolled atrial fibrillation. Prior to that time many patients were labeled as “idiopathic” DCM with atrial fibrillation as a result. It is now recognized that the reverse is often true. That is, a DCM might evolve in a patient who started with “lone” AF. It is a chronic process. Many affected patients seem to lack cardiac awareness, thus allowing them to go for long periods with high rate atrial fibrillation.

Over time it was recognized that this was more common and occurred with varying severity. There has been some evidence, for example, that the most aggressive rate control strategy, AVN ablation and pacing, may modestly improve EF (counterbalanced, of course, by the adverse effects of RV pacing unless biV pacing is part of the management strategy).

Now on the the paper, which reported distinct inflammatory and ultrastructural patterns. From the abstract:

Results Patients with TCM, on the basis of clinical criteria, had stronger myocardial expression of major histocompatibility complex class II molecule and enhanced infiltration of CD68+ macrophages compared with patients with DCM. Furthermore, when compared with patients with ICM, the presence of T cells and macrophages was significantly reduced in TCM. Myocardial fibrosis was detected to a significantly lower degree in patients with TCM compared with patients with DCM and ICM. Electron microscopic examination revealed severe structural changes in patients with TCM. A disturbed distribution pattern of mitochondria was predominantly present in TCM. Quantitative assessment of myocyte morphology revealed significantly enhanced myocyte size compared with patients with ICM. Ribonucleic acid expression analysis identified changes in metabolic pathways among the patient groups.

Conclusions TCM is characterized by changes in cardiomyocyte and mitochondrial morphology accompanied by a macrophage-dominated cardiac inflammation. Thus, further prospective studies are warranted to characterize patients with TCM by endomyocardial biopsy more clearly.

The accompanying audio file, available as open access on the abstract page, discusses a related editorial in the same issue.

An evidence summary on severe asymptomatic hypertension

Hypertension affects one-third of Americans and is a significant modifiable risk factor for cardiovascular disease, stroke, renal disease, and death. Severe asymptomatic hypertension is defined as severely elevated blood pressure (180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without symptoms of acute target organ injury. The short-term risks of acute target organ injury and major adverse cardiovascular events are low in this population, whereas hypertensive emergencies manifest as acute target organ injury requiring immediate hospitalization. Individuals with severe asymptomatic hypertension often have preexisting poorly controlled hypertension and usually can be managed in the outpatient setting. Immediate diagnostic testing rarely alters short-term management, and blood pressure control is best achieved with initiation or adjustment of antihypertensive therapy. Aggressive lowering of blood pressure should be avoided, and the use of parenteral medications is not indicated. Current recommendations are to gradually reduce blood pressure over several days to weeks. Patients with escalating blood pressure, manifestation of acute target organ injury, or lack of compliance with treatment should be considered for hospital admission.

Testosterone and cardiovascular health

From a recent review:

Testosterone (T) has a number of important effects on the cardiovascular system. In men, T levels begin to decrease after age 40, and this decrease has been associated with an increase in all-cause mortality and cardiovascular (CV) risk. Low T levels in men may increase their risk of developing coronary artery disease (CAD), metabolic syndrome, and type 2 diabetes. Reduced T levels in men with congestive heart failure (CHF) portends a poor prognosis and is associated with increased mortality. Studies have reported a reduced CV risk with higher endogenous T concentration, improvement of known CV risk factors with T therapy, and reduced mortality in T-deficient men who underwent T replacement therapy versus untreated men. Testosterone replacement therapy (TRT) has been shown to improve myocardial ischemia in men with CAD, improve exercise capacity in patients with CHF, and improve serum glucose levels, HbA1c, and insulin resistance in men with diabetes and prediabetes. There are no large long-term, placebo-controlled, randomized clinical trials to provide definitive conclusions about TRT and CV risk. However, there currently is no credible evidence that T therapy increases CV risk and substantial evidence that it does not. In fact, existing data suggests that T therapy may offer CV benefits to men.

Septic encephalopathy

Should we reinvent the physical exam?

Saturday, March 16, 2019

A single ectopic beat on a 12 lead ECG is an important predictor

Clinical Perspective
What Is New?

Among participants in 2 large, community‐based cohort studies, the presence of a premature atrial contraction detected from a single, standard 12‐lead ECG predicted a statistically significant elevated risk of both incident atrial fibrillation and death.

Similarly, a premature ventricular contraction from a single, standard ECG predicted statistically significant increased risks of incident heart failure, decline in left ventricular ejection fraction, and death.

What Are the Clinical Implications?

In combination with other risk markers, ectopy on a single, standard 12‐lead ECG may provide valuable information regarding an individual's cardiovascular risk and serve as a broadly available tool for the prediction and prevention of atrial fibrillation, heart failure, and death.

Reducing blood culture contamination with a special collection device


Blood culture contamination is a clinically significant problem that results in patient harm and excess cost.


In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5–2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection.


In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted.


Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting.

RALES disease

P wave indices and risk of ischemic stroke

Conclusions—P-wave terminal force in lead V1, P-wave duration, and maximum P-wave area are useful electrocardiographic markers that can be used to stratify the risk of incident ischemic stroke.

Friday, March 15, 2019

Spontaneous pneumothorax (apparent primary spontaneous pneumothorax) may be the first clue to certain cystic lung diseases


Purpose of review: Diffuse cystic lung diseases (DCLDs) are a heterogeneous group of disorders with varying pathophysiologic mechanisms that are characterized by the presence of air-filled lung cysts. These cysts are prone to rupture, leading to the development of recurrent spontaneous pneumothoraces. In this article, we review the epidemiology, clinical features, and management DCLD-associated spontaneous pneumothorax, with a focus on lymphangioleiomyomatosis, Birt–Hogg–Dubé syndrome, and pulmonary Langerhans cell histiocytosis.

Recent findings: DCLDs are responsible for approximately 10% of apparent primary spontaneous pneumothoraces. Computed tomography screening for DCLDs (Birt–Hogg–Dubé syndrome, lymphangioleiomyomatosis, and pulmonary Langerhans cell histiocytosis) following the first spontaneous pneumothorax has recently been shown to be cost-effective and can help facilitate early diagnosis of the underlying disorders. Patients with DCLD-associated spontaneous pneumothorax have a very high rate of recurrence, and thus pleurodesis should be considered following the first episode of spontaneous pneumothorax in these patients, rather than waiting for a recurrent episode. Prior pleurodesis is not a contraindication to future lung transplant.

Summary: Although DCLDs are uncommon, spontaneous pneumothorax is often the sentinel event that provides an opportunity for diagnosis. By understanding the burden and implications of pneumothoraces in DCLDs, clinicians can facilitate early diagnosis and appropriate management of the underlying disorders.

Pseudo subarachnoid hemorrhage in post anoxic brain injury

Emerging long term risks of proton pump inhibitors

First introduced in 1989, proton pump inhibitors (PPIs) are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. The PPIs are currently approved by the US Food and Drug Administration for the management of a variety of gastrointestinal disorders including symptomatic peptic ulcer disease, gastroesophageal reflux disease, and nonulcer dyspepsia as well as for prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. PPIs inhibit gastric acid secretion, and the most commonly associated adverse effects include abdominal pain, diarrhea, and headache. Although PPIs have had an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, and dementia. These emerging data have led to subsequent investigations to assess these potential risks in patients receiving long-term PPI therapy. However, most of the published evidence is inadequate to establish a definite association between PPI use and the risk for development of serious adverse effects. Hence, when clinically indicated, PPIs can be prescribed at the lowest effective dose for symptom control.

Thursday, March 14, 2019

Some medical axioms

Early arterial ischemic events after VTE in cancer patients

•Arterial events are a major cause of death in cancer patients with venous thrombosis.
•Arterial events occur early after venous thrombosis in cancer patients.
•The risk of arterial events should be considered in this clinical setting.



Venous thromboembolism is common in patients with malignancies, affecting up to 10% of this patient population. The association between arterial ischemic events and venous thromboembolism also has been established. However, the influence of arterial ischemic events on outcomes in cancer patients with venous thromboembolism has not been fully determined.


The current study analyzed clinical characteristics, time course, risk factors, incidence and severity of venous thromboembolism recurrences, arterial ischemic events and major bleeding in 5717 patients with active cancer and venous thromboembolism recruited into RIETE (multi-center prospective registry of patients with objectively confirmed venous thromboembolism).


During the anticoagulation course (median 7.3 months), 499 (8.7%) patients developed venous thromboembolism recurrences, 63 (1.1%) developed arterial events, and 346 (6.1%) suffered from major bleeding. Overall, major bleeding and arterial events appeared earlier (median 35 and 36 days, respectively) than venous thromboembolism recurrences (median 97 days). Thirty-day mortality rates after each event were: 20% after recurrent pulmonary embolism, 13% after recurrent deep vein thrombosis, 41% after major bleeding, 40% after myocardial infarction, 64% after ischemic stroke, and 83% after lower limb amputation. Bleeding was the leading cause of death (67 fatal bleeds), whereas cumulative mortality due to arterial ischemic events (n = 27) was similar to that related to pulmonary embolism recurrences (n = 26).


In this study, arterial ischemic events and major bleeding appeared early after venous thromboembolism in patients with active cancer and were among frequent causes of their deaths. The risk and severity of arterial events need to be considered in this clinical setting.

ARDS: are we making a dent?

An analysis of ARDSnet trials shows declining mortality since 1996:

Objectives: There has been multiple advances in the management of acute respiratory distress syndrome, but the temporal trends in acute respiratory distress syndrome–related mortality are not well known. This study aimed to investigate the trends in mortality in acute respiratory distress syndrome patients over time and to explore the roles of daily fluid balance and ventilation variables in those patients.

Design: Secondary analysis of randomized controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2013.

Setting: Multicenter study involving Acute Respiratory Distress Syndrome Network trials.

Patients: Patients with acute respiratory distress syndrome.

Interventions: None.

Measures and Main Results: Individual patient data from 5,159 acute respiratory distress syndrome patients (excluding the Late Steroid Rescue Study trial) were enrolled in this study. The crude mortality rate decreased from 35.4% (95% CI, 29.9–40.8%) in 1996 to 28.3% (95% CI, 22.0–34.7%) in 2013. By adjusting for the baseline Acute Physiology and Chronic Health Evaluation III, age, ICU type, and admission resource, patients enrolled from 2005 to 2010 (odds ratio, 0.61; 95% CI, 0.50–0.74) and those enrolled after 2010 (odds ratio, 0.73; 95% CI, 0.58–0.92) were associated with lower risk of death as compared to those enrolled before 2000. The effect of year on mortality decline disappeared after adjustment for daily fluid balance, positive end-expiratory pressure, tidal volume, and plateau pressure. There were significant trends of declines in daily fluid balance, tidal volume, and plateau pressure and an increase in positive end-expiratory pressure over the 17 years.

Conclusions: Our study shows an improvement in the acute respiratory distress syndrome-related mortality rate in the critically ill patients enrolled in the Acute Respiratory Distress Syndrome Network trials. The effect was probably mediated via decreased tidal volume, plateau pressure, and daily fluid balance and increased positive end-expiratory pressure.

Wednesday, March 13, 2019

Amp-C beta lactamase producing organisms

From a recent review:


Enterobacterales are among the most common causes of bacterial infections in the community and among hospitalized patients, and multidrug-resistant (MDR) strains have emerged as a major threat to human health. Resistance to third-generation cephalosporins is typical of MDRs, being mainly due to the production of extended spectrum β-lactamases or AmpC-type β-lactamases.


The objective of this paper is to review the epidemiological impact, diagnostic issues and treatment options with AmpC producers.


AmpC enzymes encoded by resident chromosomal genes (cAmpCs) are produced by some species (e.g., Enterobacter spp., Citrobacter freundii, Serratia marcescens), while plasmid-encoded AmpCs (pAmpCs) can be encountered also in species that normally do not produce cAmpCs (e.g., Salmonella enterica, Proteus mirabilis, Klebsiella pneumoniae and Klebsiella oxytoca) or produce them at negligible levels (e.g., Escherichia coli). Production of AmpCs can be either inducible or constitutive, resulting in different resistance phenotypes. Strains producing cAmpCs in an inducible manner (e.g., Enterobacter spp.) usually appear susceptible to third-generation cephalosporins, which are poor inducers, but can easily yield mutants constitutively producing the enzyme which are resistant to these drugs (which are good substrates), resulting in treatment failures. pAmpCs are usually constitutively expressed. Production of pAmpCs is common in community-acquired infections, while cAmpC producers are mainly involved in healthcare-associated infections.


To date, there is no conclusive evidence about the most appropriate treatment for AmpC-producing Enterobacterales. Carbapenems are often the preferred option, especially for severe infections in which adequate source control is not achieved, but cefepime is also supported by substantial clinical evidences as an effective carbapenem-sparing option.

Review of motor neuron disease

Autoimmune thyroid disease

Free full text review. From the conclusion:

The management of autoimmune thyroid disease continues to be revised by new research which includes the identification of new entities, such as IgG4-related thyroid disease and new drug-induced forms of thyroid disease; the development of novel small molecules capable of influencing mechanisms of autoimmunity; and more detailed knowledge of the risks versus benefits of thyroxine therapy in subclinical hypothyroidism.

Tuesday, March 12, 2019

The relationship between atrial fibrillation and dementia

Reviewed in the green journal. It is unclear the extent to which it may be driven by factors other than stroke.

Acute exacerbation of IPF

Adrenal crisis

Trends in the use of ACLS drugs

Objectives: Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.

Design: Observational cohort study.

Setting: Hospitals contributing data to the American Heart Association Get With The Guidelines–Resuscitation database between 2001 and 2016.

Patients: Adult in-hospital cardiac arrest patients.

Interventions: The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update.

Measurements and Main Results: A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3–1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1–2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9–4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2–0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06–0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8–2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7–2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9–2.7; p less than 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3–3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p less than 0.0001).

Conclusions: Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

Note the increased usage of bicarb and calcium. These are niche agents which are critically important in limited situations but have no place in the routine management of arrest. It is concerning that their use has increased despite being removed from ACLS protocols decades ago with a lack of high level evidence of benefit, possible evidence of harm, and the current bicarb shortage.

Effect of angiotensin II in patients with vasodilatory (mainly septic) shock requiring renal replacement therapy

Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy.

Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial.

Setting: ICUs.

Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively).

Interventions: IV angiotensin II or placebo.

Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of greater than or equal to 10 mm Hg or increase to greater than or equal to 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively.

Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.

Monday, March 11, 2019

Procalcitonin monitoring can help shorten the duration of antibiotic therapy in pneumonia


Purpose of review: Increasing antimicrobial resistance is a worldwide phenomenon that is threatening public health. Lower respiratory infections are one of the leading causes of morbidity that contribute to antibiotic consumption and thus the emergence of multidrug-resistant microbial strains. The goal of shortening antibiotic regimens’ duration in common bacterial infections has been prioritized by antimicrobial stewardship programs as an action against this problem.

Recent findings: Data coming from randomized controlled trials, meta-analyses, and systematic reviews support the shortening of antimicrobial regimens in community-acquired, hospital-acquired, and ventilator-associated pneumonia. Short schedules have been proven at least as effective as long ones in terms of antimicrobial-free days and clinical cure. Procalcitonin-based algorithms have been validated as well tolerated and cost-effective tools for the duration of pneumonia therapy reduction.

Summary: Shortening the duration of antibiotic regimens in pneumonia seems a reasonable strategy for reducing selective pressure driving antimicrobial resistance and costs provided that clinical cure is guaranteed. Procalcitonin-based protocols have been proven essentially helpful in this direction.