18 Jun 2020

June 18, 2020

Written by REBEL Cast
Background: Here we go again with another “Time is Brain,” acute ischemic stroke study.  The authors start out by saying that earlier administration of intravenous tPA in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months.  These statements are based on flawed studies [3][4] (Check out Ken Milne discussing these issues HERE). Additionally, tPA has not been demonstrated to decrease mortality in any randomized clinical trial though it does increase early mortality. If you can’t tell, I am very skeptical about the spin of this trial.
Medical Categories: Neurology
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15 Jun 2020

June 15, 2020

Written by REBEL EM
Background: Factor Xa inhibitors have gained more use over the past several years due to the ease of administration and easier monitoring. However, bleeding, namely intracranial hemorrhage (ICH) is still a risk and the lack of a proven antidote is a cause for concern. Guidelines for the treatment of ICH published in 2016 recommended the administration of prothrombin complex concentrates (PCCs, both activated [aPCC] and 4 factor) [2]. In 2018 andexanet alfa gained accelerated approval by the FDA for the reversal of factor Xa inhibitors. Despite this new antidote, many organizations such as the American Society of Hematology and the European Stroke Organization still recommend the use of PCCs.  Research thus far has been performed in healthy volunteers, or small (<100 total patients with ICH) trials leaving a gap in the literature of what agent to use at the bedside.
Medical Categories: Hematology and Oncology
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11 Jun 2020

June 11, 2020

Written by REBEL Crit, REBEL EM
Background: In end-stage renal disease (ESRD) patients on hemodialysis (HD), infection is the second most common cause of mortality after cardiovascular disease (Sarnik 2000). Because of the systemic inflammation and increased capillary permeability, septic patients are at significant risk for fluid imbalances and frequently require large volumes of crystalloids. The Surviving Sepsis Campaign guidelines provide a strong recommendation with low quality of evidence for administering a 30mL/kg fluid bolus within 3 hours of recognition of sepsis-induced hypoperfusion (Rhodes 2016). Further fluid administration should be guided by hemodynamic assessment (bedside echocardiography, passive leg-raise, etc.). In the general population, this early administration of fluids to patients with hypotension or sepsis-induced hypoperfusion has been associated with improved outcomes. However, there is significant confusion regarding the effects of a large 30mL/kg bolus on ESRD patients due to a lack of studies. While these patients may appear, volume overloaded on physical exam, they may be intravascularly volume deplete. Physicians may be hesitant to administer a large fluid bolus in ESRD patients because of the risk of precipitating cardiogenic shock, pulmonary edema, and respiratory failure. In fact, multiple studies show that patients who have ESRD are less likely to receive the full 30mL/kg fluid bolus compared to non-ESRD patients (Lowe 2018, Truong 2019, Dagher 2015). Furthermore, some studies show equivalent outcomes between ESRD patients who receive the full bolus and those who do not. We will review two studies that examined this topic.
Medical Categories: Endocrine, Metabolic, Fluid, and Electrolytes, Infectious Disease, Resuscitation
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8 Jun 2020

June 8, 2020

Written by REBEL Covid-19, REBEL EM

Background: Despite the initial excitement around the use of chloroquine (CQ) and hydroxychloroquine (HCQ), there is mounting evidence that neither drug is effective in COVID-19 treatment. Laboratory studies have shown antiviral and immunomodulatory properties in vitro but these have not held up in clinical application. However, one potential area of use that needs more investigation is the use of HCQ for post-exposure prophylaxis (PEP). As the pandemic continues, PEP becomes an increasingly important topic in stopping repeat surges of the disease. To date, there is no high-quality evidence on prophylactic HCQ after exposure.

Medical Categories: Infectious Disease
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6 Jun 2020

June 6, 2020

Written by REBEL Covid-19, REBEL EM
Background: Convalescent plasma therapy is not a new or novel therapeutic option.  It involves taking the plasma from patients who have recovered from an illness and using it to treat patients who currently have the same illness. This approach has been evaluated in the treatment of SARS, MERS, and ebola but, none of the studies in these disease showed definitive results.  Thus far, the amount of evidence on convalescent plasma therapy in COVID-19 is also limited.  There was a case series of 5 patients [2] and a systematic review of 5 trials with 27 patients [3]. Neither study was earth-shattering. However, both showed  improved weaning from mechanical ventilation and no adverse events in the convalescent plasma group.  With a total of 32 patients, we should not put any weight in either of these trials.  We now have our first randomized clinical trial on convalescent plasma therapy.
Medical Categories: Infectious Disease
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