August 24, 2020

Background Information:

It is well documented throughout the literature that critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.1–4 Acute kidney injury may be complicated by acidosis, hyperkalemia and other major metabolic disorders and thus the initiation of renal replacement therapy (RRT) is generally considered beneficial in these patients.5 In patients without these complications, the timing of when to initiate RRT remains unclear and is frequently debated. There are three trials to know before getting to this one: ELAIN, IDEAL and AKIKI. The ELAIN trial was the only one of the three to show reduced 90-day mortality with early vs delayed initiation of RRT and was the smallest in sample size.6 The IDEAL trial concluded that early planned initiation of dialysis in stage V chronic kidney disease was not associated with improvement in survival or clinical outcomes.7 Lastly, the AKIKI trial found no significant difference with regard to mortality between an early and delayed strategy of RRT and actually saw an appreciable number of patients avert the need for RRT in a delayed strategy.8 The authors of the following study sought to investigate whether an accelerated strategy for RRT would result in lower risk of death from any cause at 90 days when compared to a standard strategy of RRT initiation.

April 9, 2020

Background: Most guidelines recommend prehydration prior to iodine-based contrast media to prevent postcontrast acute kidney injury (PC-AKI) in patients with CKD.  There is, however, a lack of evidence for the effectiveness of this as well as the potential adverse effects from the hydration itself (i.e. congestive heart failure exacerbation). We have covered the AMACING trial on REBEL EM which was a randomized clinical trial evaluating prehydration with 0.9% normal saline vs no prehydration in patients with estimated glomerlular filtration rates of 30 – 59mL/min/1.73m2.  In that study there was no difference in their primary outcome of contrast induced nephropathy (now called postcontrast acute kidney injury - PC-AKI) at 2 – 6 days after IV contrast (2.7% with prehydration vs 2.6% without prehydration). The trial we are are covering today, the Kompas trial, directly compared prehydration with sodium bicarbonate vs no prehydration prior to non-emergent intravenous contrast-enhanced CT in patients with CKD stage 3.

January 16, 2020

Background: Computed tomography pulmonary angiography (CTPA) is the current gold standard for diagnosing acute pulmonary embolism in the ED.  It has a high sensitivity, and specificity, is readily available, and can establish analternative diagnoses.  One issue with CTPA is that many hospital protocols create barriers for patients with chronic kidney disease or acute kidney injury (AKI) protocols in place from getting the necessary IV contrast.  There are several studies [2][3][4] that have evaluated the causal relationship between contrast exposure and nephrotoxicity. However, most of these studies are observational and retrospective in nature. The issue with retrospective studies is that they often cannot control for confounders and observational studies cannot give us causation, only association. We now have another retrospective observational study asking the same question, which has the inherent issues of previous studies.

April 4, 2019

Background: Computed tomography (CT) scans using IV contrast agents are one of the most common imaging modalities used in the emergency department (ED). The reason for this is no secret. CT scans with IV contrast offer a large amount of information on patients when limited information is available, they are diagnostic of many conditions with good performance characteristics, and they are often requested by consultants.   Many patients get suboptimal studies without IV contrast due to fear of contrast induced nephropathy (CIN). However, more recent studies suggest that with the use of iso- and low-osmolar contrast agents (almost universally used today) this concern is unwarranted.  Most studies on this topic have focused on unselected populations, and not focused on patient groups at higher risk for AKI, including those with sepsis.

February 26, 2019

Online educational resources, social media, and asynchronous education increasingly dominate innovation and continuing medical education for practicing emergency physicians. The “Free Open-Access Medical Education” (FOAM) movement has utilized the power of global connectivity to drive narrowing of the knowledge translation window, however critics have urged caution and warned of error, as many of these resources lack peer review or quality control [1]. REBEL EM is an online educational resource widely used throughout the FOAM community, garnering an average of 3,000 - 30,000 views/engagements per educational post, and satisfying all quality indicators that have been previously identified as markers of reliability and usability for digital scholarship [2]. To this end, we at REBEL EM are conducting a survey looking at rates of certain medication usage in the treatment of renal colic.  This is the follow up survey after the publication of the LIDOKET trial.
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