March 2017

Authors: Andy Neill, Dave McCreary / Codes: CC21 / Published: 01/03/2017

Clinical Question:
Can we use longer IV cannula for ultrasound guided peripheral access?

Title of Paper:
Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery

Journal and Year:
Heart and Lung

Lead Author:
Adam Fabiani

Patients Studied:
Post cardiac surgery patients in an Italian ICU with difficult venous access needing short term venous access and not a central line. So not exactly the average ED population I know.

Intervention:
Ultrasound guided venous access with a seldinger catheter (one of the leader caths) in the mid upper arm

Primary Outcome:
Success rate (which was a silly choice as it was 100%)

Summary of Results:

  • 71 patients
  • mainly for fluids and the usual post op complication antibiotics
  • most commonly used was an 18G18cm catheter (i have used an 20g/8cm most commonly)
  • stayed in for 15 days
  • 20% removed early for complications (usually dislodged or occlusion or occasional phlebitis)
  • one case of Catheter related blood stream infection (less than 1 per 1000 catheter days which is below the best performing bundled central line i think)
  • lots of the blocked catheters had local thrombosis on ultrasound but all below the axillary and no one did anything and nothing happened

Strengths:
Well defined population with a nice protocol for insertion and care. Good follow up

Weaknesses:
Not ED, small numbers, nurse led (is this a weakness?!?) rather than doc led.

Clinical Bottom Line:
This can be fairly simply done with existing equipment and introduction of a defined protocol. We should be training nurses and techs to do this. I suspect (though not tested here) that we should be doing these lines rather than the green cannula in a 1cm deep vein…)

Other #FOAMed Resources:
EMNerd

Clinical Question:

Can we use skin glue to stop peripheral IV access falling out or tissuing?

Title of Paper:

Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomised Controlled Trial

Journal and Year:

Annals of Emergency Medicine, 2016

Lead Author:

Simon Bugden

Patients Studied:

Emergency department patients being admitted to the hospital with patent peripheral IV Cannula (IVC) in situ

Intervention:

A drop of skin adhesive glue to the point of skin insertion and under the catheter hub, in addition to standard securement (Tegaderm and tape)

Comparison:

Standard securement method of Tegaderm and Tape

Primary Outcome:

Peripheral IVC failure at 48 hours

Summary of Results:

  • 369 IVCs analysed
  • Reduction in IVC failure of 10% (27 vs 17%) with use of glue
  • Number needed to treat = 10
    • Wide confidence interval however, NNT anywhere between 5 and 50
  • Trend towards reduction in secondary measures of phlebitis, occlusion and dislodgement (though not powered for these)
  • No difference in rates of infection (as they were zero in both groups)

Strengths:

  • Straightforward study
  • Impressive follow up numbers

Weaknesses:

  • Non-blinded
  • Pretty short follow up time (48 hours), many IVCs would stay in situ longer than this

Clinical Bottom Line:

  • There may be a role for glue to prevent failure of peripheral IVCs, and its a trick to add to the arsenal
  • It would be expensive to do routinely, but perhaps theres a sub-group of patients for whom it could be considered – such as the patient with difficult IV access, or Doris in bed two on your fifth trip to replace her access.
  • If you do it – maybe let the nurses know

Other #FOAMed Resources:

Clinical Question:

What is the cure for sepsis?

Title of Paper:

Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study

Journal and Year:
Chest, 2016

Lead Author:
Paul Marik

Overview of study methods:

  • identified patients by EHR (dodgy…)
  • historical control of the patients in the year prior (dodgy….)
  • no prospective data collection
  • chart review with no clear methods

Patients Studied:
Patients in a single tertiary ICU with severe sepsis (the 1992 definitions) and procalcitonin >2.

Intervention:

  • IV Vitamin C (1.5g 6 hourly) and IV hyrdocortisone (50mg 6 hourly) and thiamine (200mg 12 hourly)

Comparison:

  • Usual ICU sepsis care (which did seem pretty typical if a bit light on the fluids)

Primary Outcome:

  • Hospital Survival

Summary of Results:

  • 47 pts in each group
  • mortality was 4/47 v 19/47 favouring the new treatment (note that means the control mortality was twice what ARISE/PROCESS/PROMISE was… and similar to the EGDT trial by Rivers…
  • they state that the ones who died in the treatment group were not related to sepsis (which is bonkers as they died from dementia, heart failure, sarcoid and COPD and were all palliated and comfort care on the ward – likely because their sepsis was killing them)
  • there was an impressive change in vasopressor use (20 hrs v 55 hrs)
  • median ICU length of stay was unchanged
  • note that 2/3 of the control got steroids anyhow so hard to know what is making the difference here

Strengths:

  • hmmm…
  • hold on a sec…
  • at least it’s realatively cheap and not pharma driven

Weaknesses:

  • huge potential for bias here on so many levels – throw your FRCEM critical appraisal skills at this and you’ll come up with loads)

Clinical Bottom Line:

  • interesting but no where near ready for clinical use
  • Come back when you’ve done a trial. Which they are doing to be fair to them.
  • “In God we trust, all others bring data…” (William Edwards Deming)

Other #FOAMed Resources:

  • the bottom line has a great summary of the trial and got it out way before we did… like most people do…
  • The talk was at Critical Care Reviews in Jan 2017 and Rob is posting the talks online so look out for it. UPDATE: The talk is now posted here. With some nice responses on twitter:

Screen Shot 2017-03-17 at 13.45.20

Clinical Question:

Does diazepam help discharged patients with acute non-radicular lower back pain?

Title of Paper:

Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Lower Back Pain

Journal and Year:

Annals of Emergency Medicine, 2017

Lead Author:

Benjamin Friedman

Patients Studied:

114 ED adult patients with acute, non-traumatic, non-radicular lower back pain for < 2 weeks

Intervention:

Naproxen 500mg BD plus Diazepam 5-10mg BD PRN

Comparison:

Naproxen 500mg BD plus Placebo BD PRN

Primary Outcome:

Improvement in Roland-Morris Disability Questionnaire between ED discharge and one week follow up

Summary of Results:

No difference (not just statistically but literally no difference – both improved by 11 points) in questionnaire score at one week between the groups

Secondary outcomes (a reasonable list – check out the paper) also looked pretty similar.

Strengths:

Prospective, randomised, double blind, placebo controlled study

Sample size calculation to assess for clinically significant difference

Objective and validated primary outcome measure

Good variety of secondary outcomes if you fancy a read

Excellent follow up to one week and three months – kept >50 in each arm in keeping with their sample size calculation

Weaknesses:

Excluded patients with radicular pain and didnt assess patients for the presence or absence of muscle spasm – surely these are the patients that would benefit the most from a muscle relaxant.

Clinical Bottom Line:

This study proves that diazepam is not an analgesic.

Ok, ok Im being facetious. This is a potentially useful study giving weight to the fact that we shouldnt be using diazepam for just any one with lower back pain, and I think that is something that can be put into clinical practice and considered when youre writing the take home prescription when these patients are ready for discharge.

Im not ready to take it out of my cocktail for the severe lower back pain with spasm and radiculopathy though.

The title of the paper should probably read “Diazepam Is No Better Than Placebo When Added to Naproxen For Acute Uncomplicated Lower Back Pain Without Radiculopathy, then Id be happy.

Other #FOAMed Resources:

St Emlyns journal clubbed this paper apparently while the ink was still drying. Seriously, how do you guys do it?

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