Saturday, May 7, 2011

2005 AHA CPR Guideline Changes Had No Effect

Most recently, the new "hands-only" CPR guidelines have received a lot of press and attention, and there's a lot of excellent research showing that any intervention that stops CPR decreases survival.  Well, the last time they revised the CPR guidelines, they were also intended to decrease CPR pauses, including changing the manner in which defibrillation was performed, making longer CPR intervals, and eliminating pulse checks after shocks.

The "Resuscitations Outcomes Consortium" did a crossover study looking at survival to hospital discharge before and after the implementation of the new guidelines...and they found no statistically significant differences.  They did find a clinically significant improvement in VT/VF survival that went from 14% to 18%, but the p-value was 0.06 - and it's hard to attribute that solely to the guidelines because there are other significant baseline differences, particularly a 28% to 34% increase in bystander CPR.

Should be interesting to see if widespread implementation of the new CPR guidelines increase overall or subgroup survival.

The paper also mentions their current studies, looking at whether automated devices improve outcomes and when AED analysis should be performed in sequence.

Thursday, May 5, 2011

Early Recognition of Massive Transfusion

From trauma resuscitation, a Chinese study trying to predict who will need massive transfusion after trauma.  They have a 7-item scoring system retrospectively derived...and it's probably not terribly helpful.

It's a nice idea, considering there's only so much blood readily available in the bank, and a lot of massive transfusion protocols are 1:1 with FFP and sometimes platelets, so advance warning based on the initial clinical evaluation would definitely be helpful.  There are some interesting pieces of information in the paper, although, I wish they had all their OR listed for massive transfusion, as opposed to just the ones that shook out from their stepwise regression.  Their highest predictor for massive transfusion - a hemoglobin < 7 g/dL with an OR 45.7.  SBP < 90 and positive CT or FAST were also predictors with useful OR.  Their rule is a little unusual for a theoretically beneficial intervention (massive transfusion), as they focus on specificity rather than sensitivity - probably due to a need to conserve blood component products.

In the end, though, I think most folks with a hypotensive trauma patient whose FAST is positive and a Hgb < 7 could clinically predict massive transfusion as well as this rule does.

Wednesday, May 4, 2011

Pediatric Sedation with Propofol

Lovely descriptive statistics of 25,000 occurrences of propofol sedation in children.

Interestingly - 75% of their sedations occurred in radiology.  My experience has primarily been to sedate children for uncomfortable procedures - but I am aware that our pediatric critical care intensivists staff the MRI machine specifically to run sedations for children for imaging.

2.3% had "serious adverse events" - although their "other adverse events" includes 1.3% who had "unexpected need for PPV", which, to me, seems rather serious.  1% had airway obstruction, another 1% had desaturation and 0.5% had apnea.  They also did some chart mining to see if anything showed up as associated with a serious adverse event.  The highest OR was only 4.6, and that was when an "upper respiratory" diagnosis was documented in the chart.  Other associations included prematurity, and then the addition of benzo, ketamine, anticholinergics, or opioids to the sedation.

I would say there are a couple emerging trends that might help further increase sedation safety - addition of end-tidal CO2 monitoring might give better warning of apnea and desaturation, and increased use of nitrous oxide may reduce the number of propofol sedations needed.  Otherwise - be ready for too much excitement in one out of fifty pediatric sedations.

Tuesday, May 3, 2011

MRSA is Everywhere and You Can't Stop It

No doubt your hospital has an infection control committee, signs for handwashing, sterile showers, plasma arc denudes, etc. and your e-mail box is filled with Journey to Zero or Destination: Excellence spam.

Unfortunately, it didn't seem to work up at Mayo.  They had ICUs where they put signs up trying to inspire more barrier precautions and hand hygiene, they did more surveillance and topical intranasal antibiotics - and the intervention group valiantly tried to obey.  They were somewhat poor in their compliance with suggested barrier precautions, but they were used far more often than in the control clusters - and they found no differences in any of their measures of MRSA or VRE colonization or infection following their intervention.

I will certainly not argue against cleanliness and godliness, but I am impressed they published this lovely negative study to confound us and make us think about how we should go about focusing our resources effectively.

Monday, May 2, 2011

News Flash: Dilaudid Treats Pain

Albert Einstein in Montefiore is singlehandedly, repeatedly pushing literature regarding appropriate titration of pain control in the Emergency Department.  They have several previously published papers describing their hydromorphone 1 + 1 protocol, describing its safety and efficacy.  This paper is their prospective, randomized version demonstrating its safety and superiority to "usual practice".  You could implement their protocol tomorrow and have better narcotic pain control in your ED.  It clearly works.

But the real issue this line of research uncovers is not that they've discovered a magic protocol.  What we're missing by taking the simple interpretation is more that our pain control in the ED is flawed.  If you look at the morphine equivalents their patients received in this article, they're preposterous.  I am a huge proponent of 0.1mg/kg for morphine - even in adults - and their mean dose in the "usual care" arm was 6mg morphine equivalents, and their mean additional dose was 3mg.  0.1mg/kg is a starting dose for morphine that gives less than 50% of patients adequate pain relief - which is where the second part of their protocol comes in.  Scheduled reassessment for pain and a standing order for additional medication is another area where "usual care" will obviously fall behind, simply because of the uncontrollable chaos of the ED.

So, my take home from this article is that protocolized, standing orders for narcotic analgesia in appropriately selected patients is safe and effective, and, you can use their protocol or develop your own.

Sunday, May 1, 2011

Ardbeg Supernova

Sunday Scotchday.

This is a rather special scotch I bought a friend as a gift.  It comes from an Islay distillery with a reputation for strong notes of peat, and this bottling is "the peatiest", hence, the special Supernova designation.  They've even gone so far as to scientifically prove the peatiness by measuring a phenol level.

What's surprising about this Scotch is how smooth it is.  Obviously, at 60% alcohol by volume, it's a harsh beverage until you dilute out the paint thinner quality - but once you do that, you it is truly a unique drinking experience in how it truly builds and explodes on your palate in a very pleasant, prolonged finish. Good luck finding this in a local store - I had to order it off the internet from a distributor who did ship to the U.S.