May 15, 2017

Background: There has been very little robust evidence published on the long-term outcomes of systemic thrombolysis in acute submassive PE.  Many advocate for the use of systemic thrombolysis to reduce morbidity (complications from chronic pulmonary hypertension) and mortality. The PEITHO trial compared systemic thrombolysis (with tenecteplase + heparin) vs no systemic thrombolysis (placebo + heparin) in just over 1000 patients with confirmed PE, RV dysfunction, and positive troponins.  The primary outcome of all-cause death or hemodynamic decompensation within 7 days occurred less frequently in the thrombolysis arm. This statistically significant difference was driven by differences in hemodynamic decompensation, not mortality - a non-patient centered outcome. Additionally, the benefit was at the risk of increased intracranial hemorrhage.  In this current study, 70% of the patients from the original PEITHO trial were followed for a 2-year follow up period, giving us some information about long-term sequelae of systemic thrombolysis in patients with submassive PE.

May 1, 2017

Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock [1].  There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock.  1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that  would affect clinical practice for those of us on the front lines. One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management.  The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients.

April 3, 2017

Background: Historically the treatment of uncomplicated appendicitis has been appendectomy. The first appendectomy performed dates back to 1735 done by Claudius Amyand. Appendectomy has been the standard treatment for acute appendicitis every since Charles McBurney described it in 1889. However, studies have shown that an antibiotic first strategy may be feasible without increased risk of perforation, sepsis, and/or death.  This other approach is called NOTA (Non-Operative Treatment of Appendicitis).  Past RCTs were from Europe and this is the first NIH grant study to question this in the US. Antibiotic first strategies are used for uncomplicated diverticulitis, but have not been used in uncomplicated appendicitis. Several reasons why this strategy may be preferred include fewer complications, less pain, and less disability than an appendectomy first strategy.  There have been a couple of systematic reviews on the issue of NOTA that came to different conclusions (Varadhan et al. BMJ 2012 and Kirby et al. J of Infection 2015). To date, no US randomized trial has evaluated an antibiotics-first approach in uncomplicated appendicitis until now.

March 23, 2017

Background: The two most important things that we can do in cardiac arrest to improve survival and neurologically intact outcomes is high quality CPR, with limited interruptions and early defibrillation. In the case of the former, the 2015 AHA/ACC CPR updates recommended a compression rate of 100 -120/min, a depth of 2 – 2.4in, allowing full recoil, and minimizing pauses. This is a lot to remember during a stressful code situation and one way many providers are offloading themselves cognitively is by the use of mechancical CPR (mCPR) devices.  In theory these devices compress at a fixed rate, and depth, with the added benefit that the machine simply does not tire out.  Additionally, use of this device allows another provider to be available for other procedures and interventions. A recent systematic review and meta-analysis in  looked at five randomized clinical trials with over 10,000 patients with out-of-hospital cardiac arrest (OHCA) (Gates 2015).  They concluded that there was no difference in ROSC, survival or survival with good neurological outcomes with the use of these devices compared to manual CPR. It is important to state that none of these studies showed increased harm either.  A new paper just published in Circulation however, argues that mCPR during OHCA was associated with lower neurologically intact survival.

February 20, 2017

Background: Many providers and health care workers place oxygen on patients as a way to overcome hypoxemia or for patient comfort. Also in STEMI patients, many of us have learned the mnemonic “MONA” to remember the treatments for acute coronary syndrome. MONA stands for morphine, oxygen, nitroglycerin, and aspirin. It is however important to remember that oxygen is a drug; just like any other drug, there are side effects.  Some of the best known side effects of hyperoxia are direct lung toxicity, peripheral vasoconstriction, and increase in production of reactive oxygen species.  The PROXI Trial (Perioperative Oxygen Fraction-Effect on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery) and the AVOID Trial (Air Versus Oxygen in Myocardial Infarction) showed increased long-term mortality and larger myocardial infarction size respectively in patients with supra-normal oxygen levels (hyperoxia). In this episode we will explore the effect of higher oxygen levels through in ICU and STEMI patients by reviewing two trials:

The Oxygen ICU Trial The SOCCER Trial