ECMO May Improve In-Hospital Cardiac Arrest Outcomes
Cardiopulmonary resuscitation using extracorporeal membrane oxygenation improved survival compared with conventional CPR alone.
Indications for using extracorporeal membrane oxygenation (ECMO) to augment cardiopulmonary resuscitation (E-CPR) are ill-defined. Researchers retrospectively analyzed outcomes in 406 patients aged 18 to 80 with witnessed in-hospital cardiac arrest who underwent CPR for at least 10 minutes in a single hospital in Korea during a 6-year period. Patients with poor baseline neurologic status, acute intracranial hemorrhage, terminal cancer, traumatic hemorrhagic shock, irreversible organ failure, or sepsis were excluded.
Resuscitation team leaders made the decision to initiate ECMO (available within 5–10 minutes during the day and 10–20 minutes at night). In most cases, E-CPR was initiated in patients with known severe left ventricular dysfunction, prolonged arrest (no return of spontaneous circulation after 10–20 minutes), or recurrent arrest. E-CPR was established in 80 of 85 patients in whom it was attempted, and conventional CPR alone was performed in 321 patients.
Using propensity score analysis, the authors calculated that the E-CPR group had significantly higher rates of survival to hospital discharge with minimal neurologic impairment (odds ratio for mortality or neurologic deficit, 0.17) and survival to 6 months with minimal neurologic impairment (hazard ratio for neurologic impairment, 0.48) than patients in the conventional CPR group. Results were similar in the subgroup of patients with arrest from cardiac origin.
Comment: Although ECMO is not available within minutes in all hospitals, it seems to provide significant benefit to patients with poor left ventricular function or prolonged or recurrent arrest. Pending a randomized trial, it is reasonable to consider using ECMO in such patients.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine December 29, 2010
Citation(s): Shin TG et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med 2011 Jan; 39:1.
2010年12月31日 星期五
2010年12月22日 星期三
ICU 血糖之控制指標
Q: At what threshold of serum glucose should insulin therapy be initiated among patients requiring intensive care?
A: Pending more data to guide the identification of optimal glucose levels, national associations recommend that insulin therapy be initiated once glucose exceeds a threshold of 180 mg per deciliter.
Q: According to most professional guidelines, what should the target serum glucose be among intensive care patients receiving insulin therapy?
A: Most professional societies recommend a target glucose level of 140 to 180 mg per deciliter for patients requiring intensive care, with the use of an established, preferably computerized insulin-infusion algorithm and close monitoring of glucose levels.
Source: NEJM Teaching Topic Dec 23, 2010 - Glycemic Control in the ICU
2010年12月17日 星期五
Etomidate可使用於敗血症
Etomidate or Midazolam for Rapid Sequence Induction in Patients with Suspected Sepsis?
Outcomes did not differ significantly with the two induction agents.
Despite studies showing no increase in adverse outcomes related to etomidate induction for intubation of patients with shock (JW Emerg Med Jul 2 2009 and JW Emerg Med Feb 13 2009), some clinicians still oppose its use in such patients. In this prospective, double-blind, randomized trial, 122 adult patients who presented to a single emergency department with suspected sepsis and indication for intubation received either midazolam (0.1 mg/kg) or etomidate (0.3 mg/kg) for induction. Sepsis was confirmed in 96 patients who had clear evidence of infection and fulfilled two of four criteria for systemic inflammatory response syndrome.
The midazolam and etomidate groups demonstrated no significant differences in median hospital length of stay (LOS) (9.5 and 7.3 days), median intensive care unit LOS (4.2 and 3.1 days), median ventilator days (2.8 and 2.1 days), or inhospital mortality (21% and 26%). Subgroup analysis of patients who survived to discharge also showed no difference in median hospital LOS between midazolam and etomidate recipients (11.3 and 11.8 days).
Comment: In this study, use of a single bolus of etomidate for induction in patients with sepsis was not associated with any deleterious outcomes. Etomidate is an ideal induction agent because of its predictable dosing, rapid onset, short duration of action, and excellent hemodynamic stability. This report adds to a growing body of well-designed studies that refute the assertion that etomidate should not be used in patients with sepsis.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine December 17, 2010
Citation(s): Tekwani KL et al. A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: A prospective, randomized study. Ann Emerg Med 2010 Nov; 56:481.
Outcomes did not differ significantly with the two induction agents.
Despite studies showing no increase in adverse outcomes related to etomidate induction for intubation of patients with shock (JW Emerg Med Jul 2 2009 and JW Emerg Med Feb 13 2009), some clinicians still oppose its use in such patients. In this prospective, double-blind, randomized trial, 122 adult patients who presented to a single emergency department with suspected sepsis and indication for intubation received either midazolam (0.1 mg/kg) or etomidate (0.3 mg/kg) for induction. Sepsis was confirmed in 96 patients who had clear evidence of infection and fulfilled two of four criteria for systemic inflammatory response syndrome.
The midazolam and etomidate groups demonstrated no significant differences in median hospital length of stay (LOS) (9.5 and 7.3 days), median intensive care unit LOS (4.2 and 3.1 days), median ventilator days (2.8 and 2.1 days), or inhospital mortality (21% and 26%). Subgroup analysis of patients who survived to discharge also showed no difference in median hospital LOS between midazolam and etomidate recipients (11.3 and 11.8 days).
Comment: In this study, use of a single bolus of etomidate for induction in patients with sepsis was not associated with any deleterious outcomes. Etomidate is an ideal induction agent because of its predictable dosing, rapid onset, short duration of action, and excellent hemodynamic stability. This report adds to a growing body of well-designed studies that refute the assertion that etomidate should not be used in patients with sepsis.
—
Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine December 17, 2010
Citation(s): Tekwani KL et al. A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: A prospective, randomized study. Ann Emerg Med 2010 Nov; 56:481.
2010年12月16日 星期四
小兒脊椎穿刺〔LP〕的最佳身體擺放位置
Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound
BACKGROUND
Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE
To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS
A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS
There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space. Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions. Flexion of the neck, did not significantly change the interspinous space.
CONCLUSIONS
The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
http://pediatrics.aappublications.org/cgi/content/abstract/125/5/e1149
BACKGROUND
Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure.
OBJECTIVE
To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound.
METHODS
A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences.
RESULTS
There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space. Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions. Flexion of the neck, did not significantly change the interspinous space.
CONCLUSIONS
The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.
http://pediatrics.aappublications.org/cgi/content/abstract/125/5/e1149
2010年12月10日 星期五
兒童鼻噴劑 Fentanyl 可有效止痛
Intranasal Fentanyl for Pediatric Fracture Pain
Children treated with intranasal fentanyl had statistically significant reductions in pain scores.
Researchers prospectively evaluated the analgesic efficacy of atomized intranasal fentanyl (2 µg/kg; maximum dose, 100 µg) in 81 children (mean age, 8 years) who presented with clinically suspected fractures to a pediatric emergency department in Wisconsin. Eligible patients had moderate-to-severe pain according to scores on the Wong Baker Faces Scale (WBS) for children ages 3 to 8 years and a 100-mm visual analog scale (VAS) for children ages 9 to 18 years. The primary outcome measure was change in pain score at 10, 20, and 30 minutes. A significant response was defined as a decrease of one face on the WBS or 13 mm on the VAS.
Among 53 children ages 3 to 8 years, median WBS pain scores decreased significantly from five faces at baseline to three at 10 minutes and two at 20 and 30 minutes; 74% and 87% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes. Among 28 children ages 9 to 18 years, mean VAS pain scores decreased significantly (by 21–27 mm) at each time point, from a mean score of 70 mm at baseline; 69% and 61% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes.
Comment:
Intranasal fentanyl is rapid and effective and avoids venipuncture. As with all opioid analgesia, additional doses might be required to reach the desired endpoint.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine December 10, 2010
Citation(s): Saunders M et al. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med 2010 Nov; 17:1155.
Children treated with intranasal fentanyl had statistically significant reductions in pain scores.
Researchers prospectively evaluated the analgesic efficacy of atomized intranasal fentanyl (2 µg/kg; maximum dose, 100 µg) in 81 children (mean age, 8 years) who presented with clinically suspected fractures to a pediatric emergency department in Wisconsin. Eligible patients had moderate-to-severe pain according to scores on the Wong Baker Faces Scale (WBS) for children ages 3 to 8 years and a 100-mm visual analog scale (VAS) for children ages 9 to 18 years. The primary outcome measure was change in pain score at 10, 20, and 30 minutes. A significant response was defined as a decrease of one face on the WBS or 13 mm on the VAS.
Among 53 children ages 3 to 8 years, median WBS pain scores decreased significantly from five faces at baseline to three at 10 minutes and two at 20 and 30 minutes; 74% and 87% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes. Among 28 children ages 9 to 18 years, mean VAS pain scores decreased significantly (by 21–27 mm) at each time point, from a mean score of 70 mm at baseline; 69% and 61% of patients, respectively, achieved clinically significant pain reduction at 10 and 30 minutes.
Comment:
Intranasal fentanyl is rapid and effective and avoids venipuncture. As with all opioid analgesia, additional doses might be required to reach the desired endpoint.
—
Katherine Bakes, MD
Published in Journal Watch Emergency Medicine December 10, 2010
Citation(s): Saunders M et al. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med 2010 Nov; 17:1155.
終於有各大醫學會出來背書該如何併用Plavix和PPI了
Consensus Document on Concomitant Use of Clopidogrel and PPIs
Proton-pump inhibitors are endorsed for clopidogrel patients at high risk for gastrointestinal bleeding.
To address the somewhat confusing literature on the interaction between proton-pump inhibitors (PPIs) and clopidogrel, a new "consensus document" has been published jointly by the American College of Cardiology, American College of Gastroenterology, and American Heart Association.
Clopidogrel is converted to its active form by the hepatic enzyme CYP2C19, which is competitively inhibited by PPIs. Although platelet function studies have shown that PPI use lessens clopidogrel-mediated inhibition of platelet aggregation, the clinical relevance of this observation has been debated.
The consensus writers make the following points:
This document will disappoint readers who expect an unambiguous algorithm that is easily applied to all patients. Nevertheless, by endorsing use of PPIs for clopidogrel-treated patients at high risk for upper GI bleeding, the authors provide validation for this widespread practice.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine December 9, 2010
Citation(s): Abraham NS et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: A focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. J Am Coll Cardiol 2010 Dec 7; 56:2051. (http://dx.doi.org/10.1016/j.jacc.2010.09.010)
Proton-pump inhibitors are endorsed for clopidogrel patients at high risk for gastrointestinal bleeding.
To address the somewhat confusing literature on the interaction between proton-pump inhibitors (PPIs) and clopidogrel, a new "consensus document" has been published jointly by the American College of Cardiology, American College of Gastroenterology, and American Heart Association.
Clopidogrel is converted to its active form by the hepatic enzyme CYP2C19, which is competitively inhibited by PPIs. Although platelet function studies have shown that PPI use lessens clopidogrel-mediated inhibition of platelet aggregation, the clinical relevance of this observation has been debated.
The consensus writers make the following points:
- Some, but not all, observational studies have shown small statistically significant higher risk for adverse cardiovascular events among patients who received PPIs and clopidogrel concomitantly (compared with clopidogrel alone). However, in the only large randomized trial (the recently published COGENT study; JW Cardiol Oct 6 2010), patients who received omeprazole plus clopidogrel had similar rates of adverse cardiovascular events and lower rates of adverse gastrointestinal (GI) events than recipients of clopidogrel alone.
- In patients with histories of upper GI bleeding and those at high risk for this complication (e.g., advanced age; concomitant use of warfarin, steroids, or nonsteroidal anti-inflammatory drugs; Helicobacter pylori infection), the benefits of PPI therapy probably outweigh the very small risk that PPI therapy will interfere with clopidogrel's efficacy.
- Patients at low risk for GI bleeding who require clopidogrel therapy should not receive concomitant PPIs.
This document will disappoint readers who expect an unambiguous algorithm that is easily applied to all patients. Nevertheless, by endorsing use of PPIs for clopidogrel-treated patients at high risk for upper GI bleeding, the authors provide validation for this widespread practice.
—
Allan S. Brett, MD
Published in Journal Watch General Medicine December 9, 2010
Citation(s): Abraham NS et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: A focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. J Am Coll Cardiol 2010 Dec 7; 56:2051. (http://dx.doi.org/10.1016/j.jacc.2010.09.010)
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