James Dargin

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access ☆

OBJECTIVES We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access. METHODS This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis. RESULTS Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications. CONCLUSION Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

Can We Trust Observational Studies Using Propensity Scores in the Critical Care Literature? A Systematic Comparison With Randomized Clinical Trials.

Objective:To assess the degree of agreement between propensity score studies and randomized clinical trials in critical care research. Data Sources:Propensity score studies published in highly cited critical care or general medicine journals or included in a previous systematic review; corresponding randomized clinical trials included in Cochrane Systematic Reviews or published in PubMed. Study Selection:We identified propensity score studies of the effects of therapeutic interventions on short- or long-term mortality. We systematically matched propensity score studies to randomized clinical trials based on patient selection criteria, interventions, and outcomes. Data Extraction:We appraised the methods of included studies and extracted treatment effect estimates to compare the results of propensity score studies and randomized clinical trials. When multiple studies were identified for the same topic, we performed meta-analyses to obtain summary treatment effect estimates. Data Synthesis:We matched 21 propensity score studies with 58 randomized clinical trials in 18 distinct comparisons (median, one propensity score study and two randomized clinical trials per comparison), for short- and long-term mortality. We found one statistically significant difference between designs (hyperoncotic albumin vs crystalloid fluids) among these 18 comparisons. Propensity score studies did not produce systematically higher (or lower) treatment effect estimates compared with randomized clinical trials, but estimates from the two designs differed by more than 30% in one third of the comparisons examined. Observational studies in critical care met widely accepted methodological standards for propensity score analyses. Conclusions:Across diverse critical care topics, propensity score studies published in high-impact journals produced results that were generally consistent with the findings of randomized clinical trials. However, caution is needed when interpreting propensity score studies because occasionally their results contradict those of randomized clinical trials and there is no reliable way to predict disagreements.

The Painful Eye

Emergency physicians are required to diagnose and treat patients who have a painful eye on a regular basis. This article focuses on ophthalmologic emergencies that range in presentation from mild to severe symptomatology and include vision and eye-threatening ailments. The etiology, pathophysiology, physical examination, and treatment of the following conditions are discussed: acute angle closure glaucoma, scleritis, anterior uveitis, optic neuritis, keratitis, and corneal abrasion. This article should provide the necessary information to allow for rapid diagnosis and initiation of appropriate treatment of the painful eye.

Emergency Department Management of the Airway in Obese Adults

Airway management in obese adults can be challenging, and much of the literature on this subject focuses on elective surgical cases, rather than acutely ill patients. In this article, we review the emergency department evaluation of the airway in obesity, discussing anatomy, physiology, and pharmacology. In addition, we describe techniques and devices used to improve intubating conditions in the obese patient. After our review of the relevant literature, we conclude that research in this particular area of acute care remains in its infancy.

Reintubation in critically ill patients: procedural complications and implications for care

IntroductionIn critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population.MethodsWe performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient’s first and last intubation.ResultsOur registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations.ConclusionIn this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.

Ruptured Abdominal Aortic Aneurysm Presenting as Painless Testicular Ecchymosis: The Scrotal Sign of Bryant Revisited

The diagnosis of ruptured abdominal aortic aneurysm (AAA) is often missed as a result of an atypical presentation, resulting in increased mortality. Here we present an unusual case of painless scrotal ecchymosis as a presentation of ruptured AAA. We review the origin of the scrotal sign of Bryant and emphasize the importance of this uncommon finding as a diagnostic aid in atypical cases of ruptured AAA.

Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders.

BACKGROUND Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN Retrospective review. SETTING Single, tertiary care center. PATIENTS Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS None. RESULTS We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.

Utility and diagnostic accuracy of bedside lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration

Purpose We investigated the feasibility and diagnostic accuracy of lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration. Material and methods We performed a prospective study of inpatients requiring MET evaluation for respiratory decompensation. A blinded investigator recorded videos of lung and lower extremity ultrasonography. The videos were reviewed by blinded investigators to determine a ultrasonography diagnosis. The accuracy of MET diagnosis and ultrasonography diagnosis were compared to the final diagnosis determined by retrospective chart review. Results The ultrasound exam was completed in 49/50 (98%) patients enrolled in the study with a mean duration of 13 ± 4 min. When excluding six cases that were not amenable to diagnosis by our algorithm, we report a lung ultrasonography diagnostic accuracy of 84% (37/44) which is similar to the accuracy of the MET clinical diagnosis of 75% (33/44) (p = 0.29). Furthermore, we report in 28/37 (76%) of cases where the lung ultrasonography diagnosis was correct, patients may have received inappropriate therapies. Conclusions Lung ultrasonography can be rapidly performed in the majority of patients with MET activation for respiratory deterioration. As an independent diagnostic test, lung ultrasonography is non‐inferior to the MET clinical assessment and may prevent unnecessary treatments if used simultaneously. HighlightsLung ultrasonography is feasible in patients requiring MET evaluation for respiratory demise.Lung ultrasonography has a comparable diagnostic accuracy to MET clinical assessment.Lung ultrasound should be interpreted in clinical context.

A Symptom-Triggered Benzodiazepine Protocol Utilizing SAS and CIWA-Ar Scoring for the Treatment of Alcohol Withdrawal Syndrome in the Critically Ill:

Background: There are limited data on the efficacy of symptom-triggered therapy for alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU). Objective: To evaluate the safety and efficacy of a symptom-triggered benzodiazepine protocol utilizing Riker Sedation Agitation Scale (SAS) scoring for the treatment of AWS in the ICU. Methods: We performed a before-and-after study in a medical ICU. A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing. Results: We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). The median duration of AWS was shorter in the postintervention (5, interquartile range [IQR] = 4-8 days) than in the preintervention group (8, IQR = 5-12 days; P < 0.01). Need for mechanical ventilation (31% vs 57%, P = 0.01), median ICU length of stay (LOS; 4, IQR = 2-7, vs 7, IQR = 4-11 days, P = 0.02), and hospital LOS (9, IQR = 6-13, vs 13, IQR = 9-18 days; P = 0.01) were less in the postintervention group. There was a reduction in mean total benzodiazepine exposure (74 ± 159 vs 450 ± 701 mg lorazepam; P < 0.01) in the postintervention group. Conclusion: A symptom-triggered benzodiazepine protocol utilizing SAS in critically ill patients is associated with a reduction in the duration of AWS treatment, benzodiazepine exposure, need for mechanical ventilation, and ICU and hospital LOS compared with a CIWA-Ar–based protocol using fixed benzodiazepine dosing.

Thrombolysis during out-of-hospital cardiac arrest: a lesson in the law of diminishing returns

Article details Evidence-Based Medicine Journal Club Edited by Eric B Milbrandt. University of Pittsburgh Department of Critical Care Medicine