Lewis Macken

Target temperature management after out-of-hospital cardiac arrest-a randomized, parallel-group, assessor-blinded clinical trial-rationale and design

BACKGROUND Experimental animal studies and previous randomized trials suggest an improvement in mortality and neurologic function with induced hypothermia after cardiac arrest. International guidelines advocate the use of a target temperature management of 32°C to 34°C for 12 to 24 hours after resuscitation from out-of-hospital cardiac arrest. A systematic review indicates that the evidence for recommending this intervention is inconclusive, and the GRADE level of evidence is low. Previous trials were small, with high risk of bias, evaluated select populations, and did not treat hyperthermia in the control groups. The optimal target temperature management strategy is not known. METHODS The TTM trial is an investigator-initiated, international, randomized, parallel-group, and assessor-blinded clinical trial designed to enroll at least 850 adult, unconscious patients resuscitated after out-of-hospital cardiac arrest of a presumed cardiac cause. The patients will be randomized to a target temperature management of either 33°C or 36°C after return of spontaneous circulation. In both groups, the intervention will last 36 hours. The primary outcome is all-cause mortality at maximal follow-up. The main secondary outcomes are the composite outcome of all-cause mortality and poor neurologic function (cerebral performance categories 3 and 4) at hospital discharge and at 180 days, cognitive status and quality of life at 180 days, assessment of safety and harm. DISCUSSION The TTM trial will investigate potential benefit and harm of 2 target temperature strategies, both avoiding hyperthermia in a large proportion of the out-of-hospital cardiac arrest population.

Alcohol and substance use by patients with psychosis presenting to an emergency department: changing patterns.

Objectives: The aim of this study was to determine the incidence of alcohol and other substance use in patients presenting to an emergency department with acute psychiatric illnesses and to clarify the role of urine drug screens. Method: This was an unblinded prospective (observational) cohort study incorporating retrospective review of patient medical records, history of alcohol and substance use, results of urine drug screens and blood alcohol concentrations. Results: Of 196 acute psychotic patients, 104 were diagnosed with schizophrenia and 92 with “other psychosis”. Results of urine drug screens were consistent with self-reported use of substances and only identified an additional 5% of substance users. Cannabis was the commonest illicit substance used by both groups of patients, followed by psychostimulants, mainly amphetamines. Younger males were more likely to use psychostimulants and to present with violence. Conclusions: Patients with co-existing mental health problems and substance use present a major problem for our emergency departments. Cannabis was the most common substance used. Youth, male gender and psychostimulant use are associated with violent presentations. A comprehensive history of alcohol and substance use is important to implement appropriate dual diagnosis treatment. Urine drug screening is recommended for patients who do not admit to substance use.

Use of an Intravascular Fluorescent Continuous Glucose Sensor in ICU Patients

Background: Hyperglycemia and hypoglycemia are associated with adverse clinical outcomes in intensive care patients. In product development studies at 4 ICUs, the safety and performance of an intravascular continuous glucose monitoring (IV-CGM) system was evaluated in 70 postsurgical patients. Methods: The GluCath System (GluMetrics, Inc) used a quenched chemical fluorescence mechanism to optically measure blood glucose when deployed via a radial artery catheter or directly into a peripheral vein. Periodic ultrasound assessed blood flow and thrombus formation. Patient glucose levels were managed according to the standard of care and existing protocols at each site. Reference blood samples were acquired hourly and compared against prospectively calibrated sensor results. Results: In all, 63 arterial sensors and 9 venous sensors were deployed in 70 patients. Arterial sensors did not interfere with invasive blood pressure monitoring, sampling or other aspects of patient care. A majority of venous sensors (66%) exhibited thrombus on ultrasound. In all, 89.4% (1383/1547) of arterial and 72.2% (182/252) of venous measurements met ISO15197:2003 criteria (within 20%), and 72.7% (1124/1547) of arterial and 56.3% (142/252) of venous measurements met CLSI POCT 12-A3 criteria (within 12.5%). The aggregate mean absolute relative difference (MARD) between the sensors and the reference was 9.6% for arterial and 14.2% for venous sensors. Conclusions: The GluCath System exhibited acceptable accuracy when deployed in a radial artery for up to 48 hours in ICU patients after elective cardiac surgery. Accuracy of venous deployment was substantially lower with significant rates of intravascular thrombus observed using ultrasound.

Trauma bypass in south-eastern Sydney: an 8-year review.

Objective:  The New South Wales (NSW) Health Department and the Ambulance Service of NSW introduced a trauma bypass system in Sydney on 29 March 1992. This study aims to review the outcomes of trauma bypass patients brought to St George Hospital, a major trauma service in south‐eastern Sydney, and to assess the performance of the current prehospital trauma triage protocol.