July 22, 2020

Take Home Points
  • Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms
  • Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli
  • All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice
  • Although not all patients will go to the operating room, surgical consult (Neurosurgery or Orthopedics) should be obtained emergently

July 16, 2020

Background: The cornerstones of sepsis management continues to include early identification, early appropriate empiric antibiotics, definitive source control, and vasopressors to support end organ perfusion. There have been multiple studies looking at the co-administration of hydrocortisone, ascorbic acid, and thiamine (known as HAT therapy or the metabolic cocktail) to help reduce mortality and reverse shock. Despite the original Marik study showing an association between HAT therapy and a 31.9% overall decrease in mortality and a 3-fold decrease in time to vasopressor discontinuation in patients presenting with severe sepsis and septic shock, the mortality benefit has not been reproduced in subsequent randomized clinical trials.  Studies focused specifically on the use of corticosteroids have demonstrated reduced time on vasopressors in patients in septic shock.  The bigger question is does vitamin C and thiamine add anything additional to help improve mortality (The ORANGES Trial)?

July 6, 2020

Background: Hydroxychloroquine (HCQ) is an antimalarial and immunomodulatory drug that is postulated to exert an antiviral effect by increasing intracellular pH resulting in decreased viral binding at the ACE2 receptor. Azithromycin is a macrolide antibiotic that also has anti-inflammatory and immunomodulatory properties which could help decrease viral replication and viral binding. Both of these medications have been used to treat COVID patients based on in vitro findings. However, in vitro studies often do not extrapolate to patient oriented outcomes. In June 2020 the US FDA revoked the prior emergency use authorization to HCQ and chloroquine (CQ) in patients with COVID-19. We now have yet another retrospective observational trial of HCQ, azithromycin, and the drugs in combination.

June 25, 2020

Definition: Suppurative infection enclosed within the epidural space

Epidemiology

  • Incidence: 2-3 cases per 10,000 hospitalized patients (Sendi 2008).
    • Rate is increasing given the rise in number of spinal procedures and anesthesia techniques
  • Mortality is low at 5%, however, if untreated paralysis may occur
  • Can occur at any age but most patients are between 50 and 70 years old.

June 23, 2020

Background: We have been in need of a sign of hope in the fight against SARS-CoV-2 as it runs from city to city overwhelming health systems.  The majority of patients will be either asymptomatic or have only mild disease.  These patients will improve for the most part with symptomatic care.  There is a smaller portion of patients admitted to the hospital and ICU requiring oxygen therapy or invasive mechanical ventilation (IMV).  In this group of patients, there has not been much promise in the way of treatments improving mortality.  Patients requiring oxygen therapy (HFNC, NIV, IMV, ECMO) are mostly in the pulmonary and hyperinflammatory stage of disease (see below figure). One theoretical option in this hyperinflammatory stage of disease is corticosteroids to help quell the immune response and potentially improve mortality outcomes.
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