Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial.
Early goal-directed fluid resuscitation is the cornerstone of therapy for septic shock, but the optimal target for goal-directed resuscitation has not been well studied. The investigators sought to determine whether lactate clearance and central venous oxygen saturation (ScvO2) are equally effective as guides for early sepsis resuscitation. A cohort of 300 patients presenting to the emergency department with septic shock were randomly assigned to resuscitation guided either by normalization of ScvO2 (above 70%) or lactate clearance (at least 10% from baseline or remaining below 2 mmol/L), in addition to standard goals for mean arterial and central venous pressure. The 2 groups did not differ in the treatments that were administered during the 6 hours of goal-directed resuscitation or during the first 72 hours of hospitalization. Death occurred in 23% of patients managed with the ScvO2 protocol and in 17% of patients managed with the lactate clearance protocol, with no difference in adverse events between the 2 groups. The investigators concluded that early goal-directed fluid resuscitation of patients with septic shock can be safely guided by either ScvO2 or lactate clearance.
Hint:
A high ScvO2 cannot always be considered normal because dysfunctional tissue oxygen extraction (as in sepsis) may lead to increased ScvO2and thus falsely reassure the clinician about the health of the patient
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JAMA. 2010;303:739-746
2010年4月29日 星期四
2010年4月27日 星期二
聲音嘶啞(hoarseness)的注意事項
Hoarseness
A useful reminder about patients who complain of a hoarse voice:
A useful reminder about patients who complain of a hoarse voice:
- Red flag symptoms are persistent hoarseness for more than three weeks, difficulty or pain on swallowing, haemoptysis, earache with normal otoscopy, weight loss, and heavy smoking or alcohol intake
- Urgent ! chest x ray is needed if hoarseness persists for more than 3 weeks (especially if the patient is a heavy drinker, smoker, or over 50 years old)
- If the x ray is positive, refer urgently for suspected lung cancer. If it's negative, refer urgently for suspected head and neck cancer
- Routine ENT referral is advised for recurrent but non persistent (less than 3 weeks) hoarseness with no red flag symptoms
- Advise patients to stop smoking, reduce alcohol intake, and improve vocal hygiene
- Treat any exacerbating conditions such as oral thrush, asthma, or rhinitis
2010年4月24日 星期六
有5%的SAH是NE正常但已中線位移
Midline Shift or Herniation in Patients with Subarachnoid Hemorrhage and Normal Neurological Exams
In a retrospective study, 5% of patients with spontaneous SAH and normal neurological exams had computed tomographic findings that contraindicated lumbar puncture.
Controversy surrounds the issue of whether computed tomography (CT) is required before lumbar puncture (LP) in patients with suspected subarachnoid hemorrhage (SAH) and normal neurological examinations. These authors retrospectively reviewed records of 73 patients with final diagnoses of spontaneous SAH who underwent CT after presenting with sudden-onset severe headaches and normal neurological examinations.
Two neuroradiologists who were blinded to patient outcomes and original CT interpretations reviewed the scans for evidence of herniation or midline shift >2 mm. The radiologists agreed that brain herniation or midline shift was present in 4 of the 73 cases (5%); only 1 of these cases was identified in the initial radiology report. The radiologists disagreed with each other about the presence of herniation or shift in 4 cases (5%); in all 4 cases, CT scan results were considered negative for herniation or shift in the initial report.
Comment: The authors' recommendation that CT be routinely performed before LP in patients with suspected SAH is overreaching, given their study's limitations. However, new-generation CT scanning picks up most cases of SAH noninvasively, so the best approach is to obtain a CT scan first and follow with LP if the scan result is negative.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine April 23, 2010
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Citation(s):
Baraff LJ et al. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med 2010 Apr; 17:423.
Abstract
OBJECTIVES: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift.
METHODS: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift.
RESULTS: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report.
CONCLUSIONS: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
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In a retrospective study, 5% of patients with spontaneous SAH and normal neurological exams had computed tomographic findings that contraindicated lumbar puncture.
Controversy surrounds the issue of whether computed tomography (CT) is required before lumbar puncture (LP) in patients with suspected subarachnoid hemorrhage (SAH) and normal neurological examinations. These authors retrospectively reviewed records of 73 patients with final diagnoses of spontaneous SAH who underwent CT after presenting with sudden-onset severe headaches and normal neurological examinations.
Two neuroradiologists who were blinded to patient outcomes and original CT interpretations reviewed the scans for evidence of herniation or midline shift >2 mm. The radiologists agreed that brain herniation or midline shift was present in 4 of the 73 cases (5%); only 1 of these cases was identified in the initial radiology report. The radiologists disagreed with each other about the presence of herniation or shift in 4 cases (5%); in all 4 cases, CT scan results were considered negative for herniation or shift in the initial report.
Comment: The authors' recommendation that CT be routinely performed before LP in patients with suspected SAH is overreaching, given their study's limitations. However, new-generation CT scanning picks up most cases of SAH noninvasively, so the best approach is to obtain a CT scan first and follow with LP if the scan result is negative.
—
Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine April 23, 2010
----
Citation(s):
Baraff LJ et al. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med 2010 Apr; 17:423.
Abstract
OBJECTIVES: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift.
METHODS: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift.
RESULTS: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report.
CONCLUSIONS: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
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