August 22, 2019

Background: Unwarranted use of antibiotics has several deleterious effects which include, antimicrobial resistance, wasted resources, adverse effects, negative affect on the microbiome of patients, and distracts from potentially more effective interventions. There has recently been a huge push for tests such as procalcitonin to help in curtailing the use of antibiotics when it is not warranted.  Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend only prescribing antibiotics in moderately or severely ill patients with acute COPD exacerbations, increased cough, and/or sputum purulence [2]. The authors of this trial wanted to test another such marker, point of care CRP in patients with acute COPD exacerbations.  Along with bronchodilators and steroids, antibiotic prescriptions seem to be a common treatment modality as well. CRP is an acute-phase protein that is readily available and can be measured quickly with point of care testing.  The authors of this trial hypothesized that the results of POC CRP may help inform prescribing decisions for acute COPD exacerbations, however RCTs regarding clinical effectiveness of this test are lacking.

August 21, 2019

Take Home Points

  • Myxedema coma is severe, decompensated hypothyroidism with a very high mortality.
  • Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation
  • Work up includes looking for and treating precipitating causes, most commonly infection as well as serum levels of TSH, T4 and cortisol
  • Treat for the possibility of adrenal insufficiency with stress dose steroids such as hydrocortisone 100 mg IV
  • The exact means of thyroid replacement is controversial. Definitely given 100-500 mcg levothyroxine and discuss the simultaneous administration of T3 with your endocrine and ICU teams.

August 19, 2019

Background: Antibiotics are one of the cornerstones of therapy in the treatment of sepsis/septic shock, however according to the Surviving Sepsis Campaign (SSC) guidelines, time to antibiotics is a core measure, though there is weak evidence in support of this.  Most of the evidence supporting this is based off retrospective studies that showed delays in the administration of antibiotics after the development of septic shock is associated with an increase in mortality of almost 7.6% per hour [3]. The major issues with retrospective studies are that they are uncontrolled, chart quality may be inaccurate, baseline status of patients may be unbalanced and thus allow selection bias that can affect the results. Although, prospective observational studies have failed to consistently show an association between early antibiotics and mortality benefit, the guidelines still recommend early antibiotic administration within an hour of sepsis recognition.

August 15, 2019

Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, thus requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation and false positive results. These issues are compounded in patients with pregnancy. While we know that pregnancy increases risk of venous thromboembolism (VTE) our testing rates far exceed the added risk exposing thousands of women to the afore mentioned potential harms.

In 2017, the YEARS algorithm established a simplified algorithm for evaluation with a two-tiered D-dimer threshold in an effort to reduce the number of patients getting CTPA  (van der Hulle 2017). The YEARS algorithm asks three questions: 1) Are there clinical signs of DVT? 2) Does the patient have hemoptysis? and 3) is PE the most likely diagnosis. If the answer to all 3 questions is no, the D-dimer threshold is set at 1000 ng/mL FEU (500 ng/mL DDU) and if the answer is “yes” to any of the 3 questions, the D-dimer threshold is set at 500 ng/mL (250 ng/mL DDU). However, this study had very few pregnant women enrolled.

August 12, 2019

Background:  In patients with ICH, antiplatelet therapy is withheld due to the perceived risk of hematoma expansion.  Often, these medications are either not restarted or there is prolonged delays until they are restarted, but the risk of occlusive vascular events might be higher without resumption of antithrombotic therapy. A meta-analysis of observational studies found no difference in the risk of hemorrhagic events and a lower risk of occlusive vascular events associated with antiplatelet therapy resumption after any type of intracranial hemorrhage (ICH); however, randomized trials for antiplatelet efficacy in occlusive vascular disease have excluded patients with a history of intracerebral hemorrhage. Due to the paucity of evidence, no guidelines have strong recommendations about long-term anti-platelet therapy after ICH. The RESTART Trial [1] aimed to address the question of whether or not to start antiplatelet therapy following an intracerebral hemorrhagic stroke.