April 28, 2021

Background: It has long been thought that intravenous contrast can lead to acute kidney injury. Recent data, however, has called this dogmatic teaching into question.  Unfortunately, the data arguing against the association of contrast with AKI comes from observational trials and, thus, carry with it numerous biases.  One potential bias is baseline differences in the risk between exposure groups with patients not receiving contrast perceived to be at higher risk and those receiving contrast at lower risk of PC-AKI. Another example is selection bias due to requiring subsequent renal function testing in patients deemed to be higher risk and not those at lower risk.  Both of these can form a control group at high risk of kidney injury which creates a bias in favor of contrast and potentially masking harm.

November 30, 2020

Background: Renal colic and migraine headaches are common emergency department presentations.  There are a wide range of medications available to treat pain from these disorders including opioids and non-steroidal anti-inflammatory drugs. Opioids have two major issues: dependency and side effects (i.e., apnea, vomiting, etc.). Having multiple medication options is essential in our efforts to reduce the use of opioids as first line therapy for pain control.

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.