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April 2019

Author: Mark Winstanley / Codes: CAP1, CAP20, HAP14, HAP19, HMP4, PAP1, PMP4, PMP5 / Published: 01/04/2019

This month’s guideline section covers the updated NICE CKS published in Sept 2018.

Suspected DVT is a pretty common presentation at both of our EDs and affects 1: 1000 people.

Provoked DVT is a DVT associated with a transient risk factor such as significant immobility, surgery, trauma, and pregnancy. These risk factors can be removed, thereby reducing the risk of recurrence

Unprovoked DVT is a DVT occurring in the absence of a transient risk factor. The person may have no identifiable risk factor or a risk factor that is persistent and not easily correctable (such as active cancer or thrombophilia)

Two level Wells score is still recommended for risk stratification – if likely do a scan within 4 hours, if unlikely then scan them if the D-Dimer is positive.

Treatment is with an oral anticoagulant using warfarin or a DOAC or heparin based injections. Interestingly there is no RCT on the use of anticoagulant to treat VTE and is based on some historical retrospective case series.

If you find someone with an unprovoked DVT then you need to investigate further for malignancy and thrombophilia.

References:

cks.nice.org.uk deep vein thrombosis
vascular.cochrane.org cochrane vascular thromboembolism

Authors:

  • Dave McCreary
  • Andy Neill

Clinical Question:

How does CRT compare to lactate to guide fluid resuscitation in septic shock?

Title of Paper:

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion vs Serum Lactate Levels on 28-Day Mortality Among Patients with Septic Shock – The ANDROMEDA-SHOCK Randomised Clinical Trial

PMID [30772908]

Journal and Year:

JAMA 2019

Lead Author:

Glenn Hernandez

Background:

  • Sepsis is bad. Septic shock is very bad.
  • We’ve had lactate drilled into us as a measure / surrogate marker to indicate tissue hypoperfusion and guide our resuscitation
  • We need some way of gauging how successful we are when resuscitating the shocked patient
  • Some studies have suggested serial lactate measurements to assess clearance rate. This can be arduous, expensive or impractical for some centres
  • Capillary refill time is an easy bedside test (and we automatically check it in sick kids) of peripheral perfusion
  • Can resuscitation guided by this peripheral perfusion measure be effective?

Study Design:

Multicentre randomised clinical trial

Patients Studied:

  • Adults ICU patients admitted with septic shock
  • Suspected/confirmed infection
  • Lactate 2
  • Requiring vasopressors for MAP 65 after 20ml/kg fluid resuscitation

Intervention:

  • Capillary refill time measurement every 30 minutes until normalisation then every hour during the study period (8 hours)
  • Normal considered to be <3s

Comparison:

  • Lactate measurements every 2 hours
  • Normal considered <2 or decrease by 20% every 2 hours

What they did:

  • Measure fluid responsiveness
  • 500ml crystalloid to responders until either:
  • Goal reached (CRT <3s or Lactate normal/dropped 20%)
  • CVP safety limit reached
  • Patient no longer fluid responsive

Outcomes:

  • Primary: All cause 28 day mortality
  • Secondary: Death at 90 days | organ dysfunction | ventilator free days | RRT free days | vasopressor free days | ICU & Hospital LOS
    Summary of Results:
  • Primary:
  • Peripheral perfusion (CRT) group – 34.9% mortality
  • Lactate group – 43.4% mortality
  • -8.5% difference | 95% CI -18.2 – 1.2 | p=0.06

Authors Conclusion:

Among patients with septic shock, a resuscitation strategy targeting normalisation of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28 days mortality.

Clinical Bottom Line:

  • Yeah, they didn’t reach significance, but there was a definite trend favouring improvement in 28 day mortality and that is probably supported by the lesser volumes of fluids the CRT group got. The lactate group got more fluid, more vasopressors and more adrenaline, probably while chasing a number that takes longer to correct.
  • I think this study shows promise for a test thats really easy for use to perform in the ED. BUTit would have to be a proper, objective assessment like they used here, I dont think the squeeze, squint and “yeah thats around 3 seconds” would cut it here.
  • It’s worth remembering these were not our usual resus patients – these are patients on the ICU (with all the bells and whistles and fully wired for sound), theyd all already had their initial fluid bolus as per surviving sepsis, and they were on vasopressors, so its not directly applicable to our usual population.
  • Finally, this also shows us the importance of assessing fluid resuscitation – it’s not just about chasing lactate (or capillaries), its a two step question 1) Is there evidence of hypo perfusion (based on whichever marker Im chasing)? 2) Is the patient likely to be fluid responsive?
  • Another thought – should we be chasing fluid responsiveness at all? Is it just another goal directed therapy waiting to go out of vogue?

Other #FOAMed Resources / References:

Rory Speigel covered this on his EMNerd Blog – [The Case of the Deceitful Lantern]

Authors:

  • Andy Neill
  • Dave McCreary

Clinical Question

Can we skip the surgery in appendicitis?

Title

  • Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial

Author

  • Salminen, 2018, JAMA

Background

  • This has been around for a while and there are already a few RCTs on this that can be read as positive or negative depending on your perspective.
  • It’s always been clear that some people who get antibiotics will still need the appendix out later on. It’s not been clear what that number is and knowing the long term outcomes would really help in helping patients make an informed decision

Methods

  • The original trial here was an RCT looking that randomised CT confirmed appendicitis to ertapenem IV for 3 days followed by one week of levofloxacin versus usual surgical care

Results

  • There were 530 patients in the original trial
  • Recurrence was 27% at one year and 39% at 5 years
  • Balance this with 25% complication rate vs 6.5% in the antibiotic group. Though not that most of these complications were minor and not requiring surgery

Thoughts

  • There are very much two schools of thought on this. 1) why would you ever consider doing this when there is a 40% failure rate – you wouldn’t do this for anything else?!? 2) wow – i have an almost 2/3 chance of avoiding surgery – sign me up!
  • This seems a perfect option for shared decision making. I know my own decision making is massively biased by the fact that i’m a doctor and I hate the idea of my appendix still in there ready to come back and haunt me -i think i’d have mine chopped out. But we should understand that we all have all kinds of biases and emotional responses that influence decision making and these numbers are really helpful to people in making that decision. I think a reasonable person could choose either option here

Other items you may enjoy

FEEL Part 1 It is most useful in the non-shockable side of the algorithm and can be an aid when considering the 4 Hs and the 4 Ts of the ALS Algorithm
Exit Block Exit block occurs when patients in the emergency department who require admission to the hospital are unable to be moved to a bed on a ward because of...a lack of availability
Nocebo Nocebo

2 Comments

  1. Richard Edward Orrill says:

    Great Podcast. Lots to reflect upon.

  2. sibaira5853 says:

    very useful and interesting. specially about sepsis.

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