Norepinephrine Outperforms Dopamine in Adults with Septic Shock
Use of norepinephrine was associated with a 9% reduction in mortality compared with dopamine.
According to the Surviving Sepsis Campaign guidelines, norepinephrine or its precursor, dopamine, are both recommended as first-line treatments to improve organ perfusion in patients with septic shock. To determine which vasopressor is better, researchers conducted a meta-analysis of six randomized trials that compared the two agents in patients with septic shock and that reported in-hospital or 28-day mortality.
The trials included a total of 995 patients randomized to norepinephrine and 1048 randomized to dopamine. Overall, mortality was significantly lower in the norepinephrine group than in the dopamine group (48% vs. 53%). Arrhythmias were significantly less common with norepinephrine than with dopamine (relative risk, 0.43).
Comment: This study suggests that norepinephrine is superior to dopamine for adult patients with refractory septic shock. The finding that dopamine is associated with more arrhythmias might explain the higher mortality, as arrhythmias can impair cardiac function, thereby leading to worse outcomes.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 22, 2011
Citation(s): Vasu TS et al. Norepinephrine or dopamine for septic shock: A systematic review of randomized clinical trials. J Intensive Care Med 2011 Mar 24; [e-pub ahead of print].
http://dx.doi.org/10.1177/0885066610396312
2011年4月22日 星期五
2011年4月8日 星期五
Midazolam plus Ketamine
Adding Midazolam to Ketamine for Procedural Sedation Reduces Emergence Reactions in Adults
Coadministration significantly reduced incidence of emergence reactions, and route of ketamine administration had no effect on incidence of adverse events.
Ketamine is associated with untoward emergence reactions after procedural sedation, including nightmares and hallucinations. Coadministration of midazolam to mitigate this reaction is ineffective in children. Researchers assessed the effect of midazolam on incidence of ketamine emergence reactions and the effect of route of ketamine administration on incidence of adverse events in adult patients undergoing procedural sedation. In a prospective, double-blind, placebo-controlled study, 182 patients (age range, 18–50) at an academic emergency department in Turkey were randomized to receive ketamine either intravenously (1.5 mg/kg) or intramuscularly (4.0 mg/kg), either with or without intravenous midazolam (0.03 mg/kg).
Recovery agitation occurred significantly less frequently when midazolam was coadministered with ketamine (8% vs. 25%). Incidence of adverse events (recovery agitation, respiratory events, nausea and vomiting) was similar with the two routes of ketamine administration; no patient had respiratory compromise.
Comment: Coadministration of midazolam with ketamine in adults seems to mitigate emergence reactions with no significant downside.
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Richard D. Zane, MD, FAAEM
Published in Journal Watch Emergency Medicine April 8, 2011
CITATION(S): Sener S et al. Ketamine with and without midazolam for emergency department sedation in adults: A randomized controlled trial. Ann Emerg Med 2011 Feb; 57:109.e2.
2011年4月5日 星期二
硬幣卡食道不必每個都要插endo處理！
Rapid Sequence Intubation for Esophageal Coin Removal in Kids
Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted more than 30 minutes and half the patients had complications.
Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.
Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.
Comment:
Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 1, 2011
CITATION(S): Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28.
Rapid sequence intubation by emergency physicians resulted in coin removal in 95% of patients, but 10% of procedures lasted more than 30 minutes and half the patients had complications.
Esophageal coins pass spontaneously in children about 25% of the time, but most coins must be actively removed. Methods of removal in the emergency department (ED) include bougienage, Foley catheter, and Magill forceps. Endoscopy under general anesthesia typically is not performed in stable patients and, in stable patients, is delayed until patients have fasted and intubation can be performed in a more controlled setting than the ED. These authors report a 4-year retrospective review of 101 children (age range, 4 months–13 years) who underwent rapid sequence intubation (RSI; usually with succinylcholine and etomidate) for coin removal by emergency physicians at a pediatric ED in California.
Median time from ingestion to presentation was 5 hours. Coins were successfully retrieved in 96 patients, with Magill forceps alone (56 patients) or Magill forceps plus a Foley catheter (40 patients). Complications occurred in 46 patients and included minor bleeding (13 patients), lip lacerations (7), multiple attempts (5), hypoxia (2), accidental extubation (3), dental injuries (3), and bradycardia (2) despite pretreatment with atropine in 84 cases. Median ED length of stay was 5 hours (range, 1.5–45 hours), and median time from intubation to extubation was 15 minutes (range, 2–93 minutes); nine procedures lasted more than 30 minutes.
Comment:
Even at this tertiary referral center, almost 10% of procedures lasted longer than 30 minutes and nearly half the patients had complications. Faster, safer, simpler, less-expensive, and less resource-intensive techniques are more appropriate for removal of esophageal coins in most children. Why this aggressive RSI approach was used in the children in the study is unclear; however, it should be reserved for difficult cases and performed in an area of the hospital with dedicated resources.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine April 1, 2011
CITATION(S): Bhargava R and Brown L. Esophageal coin removal by emergency physicians: A continuous quality improvement project incorporating rapid sequence intubation. CJEM 2011 Jan; 13:28.
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