Friday, May 11, 2012

Suprapubic Tap Should Be Used for Urinalysis in Children?

"Ideally, SPA should be used for microbiological assessment of urine in young children," states the abstract conclusion for this article from Australia.

Looking retrospectively at urine samples from 599 children with an average age of 7 months, these authors conclude that suprapubic aspiration is superior to all other methods of obtaining urine samples for contamination rates.  Contamination rates were 46% with bag urine, 26% for clean catch, 12% for catheterization, and 1% for suprapubic aspiration.

We generally rely on catheterized urine samples in our Emergency Departments - and we even have difficulty convincing some parents that this is required, let alone a suprapubic aspiration.  In fact, I'm rather surprised they had 84 patients (14%) in their cohort receiving suprapubic aspiration, considering I have never seen it performed.

While I have no issue with their conclusion from a microbiologic accuracy standpoint, I'm not so sure such an invasive and painful procedure has a place in routine practice.

"Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: An observational cohort study."

Wednesday, May 9, 2012

A Chest Pain Disposition Decision Instrument

This article has three things I like - information graphics, informed patients, and an attempt to reduce low-yield chest pain admissions.  Unfortunately, in the end, I'm not sure about the strategy.

This is a prospective study in which the authors developed an information graphic attempting to illustrate the outcome risks for low-risk chest pain presentations.  They use this information graphic as the intervention in their study population to help educate patients regarding the decision whether to be observed in the hospital with potential provocative stress testing, or whether they would like to be discharged from the Emergency Department to follow-up for an outpatient provocative test.  They were attempting to show that use of this decision aid would lead to increased patient knowledge and satisfaction, as well as reduce observation admissions for low-risk chest pain.

The good news: it definitely works.  Patients reported increased knowledge, most were happy with the decision instrument, and a significantly increased proportion elected to be discharged from the Emergency Department - 58% of the decision aid group wanted to stay vs. 77% of the "usual care" arm wanted to stay.

My only problem: this study truly exposes the invalidity of our current management of chest pain.  If these patients are low-risk and they're judged safe enough for the outpatient strategy in this study – why are any of them being offered admission?  Of course, it's probably because they don't have timely follow-up, and AHA guidelines dictate stress testing urgently following the index visit.  But, truly, in an ideal world, few (if any) of these low-risk patients – such as the one who ruled in by enzymes – should be offered admission.

But, other than that, I'm all for information graphics and patient education techniques to include them in a shared decision-making process!

"The Chest Pain Choice Decision Aid : A Randomized Trial"

Monday, May 7, 2012

Outpatient Management of PE - With ERCast

Hosted by the mellifluous Rob Orman, we discuss a couple recent articles regarding the outpatient management of low-morbidity pulmonary emboli.  Short summary:  overdiagnosis of pulmonary emboli of uncertain clinical significance notwithstanding, the key to managing physiologically intact patients with pulmonary emboli is close follow-up to minimize the length of time patients are subject to dual anticoagulation.

Listen at:  ERCast - Pulmonary Embolus Outpatient Treatment

The Legend of the Therapeutic Arterial Line

As many Emergency Physicians can probably attest, one of the curious practices of critical care is to catheterize every potential organ system - as though the presence of these catheters in some way improves outcomes.  And, the theory is - the non-invasive numbers are not accurate enough upon which to base treatment options.

So, this is a simple study performed in an intensive care unit in which patients with arterial blood pressure monitoring receive non-invasive measurements at the arm, ankle, and thigh (not everyone in the ICU will have an accessible arm).  And, essentially, the results show - even in the critically ill, even on vasopressors - that the mean arterial pressure in the arm is probably a accurate measurement, with a mean bias of 3.4 mmHg.  The systolic and diastolic numbers, as well as the ankle and thigh values, were not quite as precise or accurate.

For the Emergency Department, it probably tells you it's OK to do what you probably already do - critically ill patients get arterial lines only if there is a luxury of time available.  Someone else with half an hour to spare can poke around fruitlessly in the radial wrist before surrendering to the femoral....

"Noninvasive monitoring of blood pressure in the critically ill: Reliability according to the cuff site (arm, thigh, or ankle)"