11 Mar 2019

March 11, 2019

Written by REBEL Crit
Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion.  Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time.  Its easy-to-use, requires no resources, and costs nothing.  To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults.
Medical Categories: Infectious Disease
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28 Feb 2019

February 28, 2019

Written by REBEL Crit
Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control.  Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved. There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality.  The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association).
Medical Categories: Infectious Disease
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25 Feb 2019

February 25, 2019

Written by REBEL EM

Introduction: The production and release of new antibiotics is rare and should be celebrated by clinicians. As antibiotic resistance continues to mount, our options narrow and, in turn, our patients suffer. Recently, the NEJM published two articles on a new antibiotic that was recently FDA approved - omadacycline. The articles compared omadacycline to moxifloxacin in the treatment of community acquired pneumonia (CAP) and to linezolid in the treatment of skin and soft tissue infections. Both studies yielded promising results for the new drug which should be cause of excitement. However, significant biases, methodological flaws and poor selection of comparator treatments should temper our excitement.

Both studies tested the new antibiotic in a non-inferiority set up. Non-inferiority studies seem to be increasingly prevalent in the literature and because they serve an important purpose, it’s important for us to understand them and also to understand why this approach is used and why it may not be appropriate.

Medical Categories: Infectious Disease
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14 Jan 2019

January 14, 2019

Written by REBEL EM

Article: Uyeki TM et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis 2018. PMID: 30566567

Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood.

Medical Categories: Infectious Disease
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3 Jan 2019

January 3, 2019

Written by REBEL Cast

Introduction: Beyond the Data

The evolution from eminence-based to evidence-based care has come to define bedside emergency medicine, with rigorous skepticism and scholarly consideration accelerated by the power of global connectivity. Where anecdote and opinion once drove therapy, clinicians now approach clinical conundrums with deliberate reflection, expecting—and at times demanding--ever-higher proof of perfection prior to implementing or incorporating therapies, tests, or approaches into their own practice. Such cogitation ensures excellence and safety and avoids pitfalls of over-adoption or confounding. Unfortunately, so many of our daily decisions are made in a space devoid of definitive data, and require a synthesis of relevant literature with our accumulated knowledge and experience—a departure from evidence-based medicine into the pragmatic world of evidence-informed medicine. It is only at this precipice—where studies and statistics simply don’t exist—that we change, where we push forward the boundaries of care, and develop not only experience, but the very questions which will define the next advances in emergency medicine. It’s with this in mind that we present this REBEL post, an entry not so much a look back on manuscripts which dictate our practice, but a treatise to help us look forward. To not inform, but to inspire thought and inquiry.  
Medical Categories: Infectious Disease
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