February 2018

Kerstin De Witt (nee Hogg) is an Emergency Physician and Thrombosis Physician and Researcher in Canada

We talk about the use of DOACs in VTE and potential reversal agents

When thinking of starting a DOAC, checking the creatinine clearance is really important. If it is <25mm, then it’s probably not advised. Recent bleeding would need thinking about. Also think about interacting medications – especially anticonvulsants where alternative anticoagulants are normally available. Cancer patients should probably be on low molecular weight heparin – we know for sure LMWH is better than warfarin, but we don’t know about the DOACs yet. We should also avoid them in pregnancy, and breastfeeding patients.

Reversal of DOACs is interesting – and they are known to cause bleeding, especially GI. In patients bleeding on dabigatran, we have idarucizumab

Kerstin De Witt, Andy Neil

Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours [link]

Author: Nor’azim Yunos et al. Emergency Medicine Australasia. 2017

Background:

• Normal saline isn’t normal. It’s got physiologically high concentrations of sodium and chloride (especially the latter).
• There have been previous studies assessing chloride restrictive fluids like Hartmann’s (“Ringer’s” for any Americans out there) and plasmalyte and their effects on renal function and mortality in critically unwell and surgical patients, with varying results.
• This study aimed to look at everyone getting fluids and being admitted through the ED to assess if restriction of Chloride reduced the incidence of AKI.

Methods

• Prospective, open-label, before-and-after study
• All consecutive adult admissions through a single Melbournian ED during a 6 month control and 6 month intervention period
• Control period = docs could prescribe fluids as was their want (0.9% saline / compound sodium lactate (Hartmann’s) / Plasma-Lyte / Gelofusin
• Treatment period = Only chloride restrictive (Hartmann’s & Plasma-Lyte) we’re available for general use. Chloride-rich fluids were special order only (hyponatraemia, traumatic brain injury or prescription by an ED specialist)
• There was a 6 month ‘washout’ period between control & intervention to educate & shift practice
• Primary outcome – incidence of AKI according to the KDIGO creatinine definitions (see section 2 here if you’re interested) during hospital admission.

Results

• Control = 5008 admissions (4299 patients)
• Intervention = 5146 admissions (4339 patients)
• 99% reduction in 0.9% saline prescription (7200 to 79 L) & Gelofusin (112 to 1.5 L)
• 89% & 79% increase in Hartmann’s & Plasma-Lyte use, respectively
• Average chloride 238 to 181mmol per admission
• Average sodium 243 to 215mmol per admission
• Primary outcome – control period patients had significantly greater chance of developing stage 3 KDIGO AKI with adjusted hazard odds ratio of 1.74

Bottom Line

• While we’ve not seen a mortality difference, if I had the choice I’d rather not have an AKI, thanks, so give me the balanced fluids please.

Andy Neil, Dave McCreary

CMP5 (Shock), CAP22 (Oliguric Patient)

Dan Horner is an Emergency Physician and Intensivist in Salford. He has a research interest in VTE and we chatted about the current state of prophylaxis for lower limb immobilisation in ED patients

The 3 recent studies:

POT-KAST

D-KAF

PROTECT Trial

DOACs for Prophylaxis

RCEM Guidance and Example protocol.

Further Reading:

Dan Horner at StEmlyns on POT-KAST trial

Dan Horner on RCEM Learning on D-KAF

Dan Horner at StEmlyns on the TILLI Project

Dan Horner, Andy Neill

CAP 20

Jon Jones is a consultant in EM in Leeds and has a particular interest in major trauma involved in both the RCEM committee on major trauma and his local major trauma network. We’ve spoken to him in September and August 2016.

This interview was recorded at the RCEM Annual Scientific Conference in Liverpool in October 2017

All of the references discussed in his talk are available in the link.

Jon Jones @jmjleeds, Andy Neill

CMP3, HMP3

We should be diagnosing Acute Kidney Injury using the AKIN criteria (modified RIFLE). There are three stages.

Once AKI is diagnosed, we need to think about the cause, and not just blindly give everyone fluid. We need to:

– Treat any likely precipitating factors and look really carefully for sepsis

– Check for an obstruction, including bladder. Do urinalysis

– Check basic bloods, including a VBG

Not everyone needs a serum rhubarb checking. Think carefully!

References:

London AKI app

AKI Care Bundles

RIFLE classification

CAP22

Jacob De Wolff @jfdwolff , Charlotte Davies

Title: Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

Author: Bhatt et al. JAMA Paediatrics, August 2017

Background

• Kids get hurt
• Kids need sedation
• Everyone has an opinion on the best way to do it but generally ketamine rules supreme
• What are the risks?

Methods

• Multicentre, prospective cohort study at 6 tertiary paediatric Emergency Departments in Canada
• Population: Children  undergoing procedural sedation by ED physicians for painful procedure
• Intervention: Sedation – any single or combination of agents used
• Primary Outcomes:
  • Significant Adverse Events (SAE) – apnoea, laryngospasm, hypotension, bradycardia, complete airway obstruction, clinically apparent pulmonary aspiration, permanent neurologic injury, death
  • Significant interventions – positive pressure ventilation, intubation, administration of vasoactive medication, neuromuscular blockade, CPR
  • Oxygen desaturation – desaturation and ≥1 intervention to improve saturation
  • Vomiting
• Secondary outcomes:
  • Sedative dose
  • Duration of sedation
  • ED LOS
• Risk factors examined: demographics, ASA, health risks, respiratory illness, preprocedural opioids, fasting status, procedure type, personnel present, duration of procedure, pre procedural antiemetic, pre oxygenation

Results

• 6295 patients included in final analysis
• Mean age 8.0
• 95% of sedations were successful
• 0.9% of procedures couldn’t be completed under sedation
• No unplanned admissions
• Ketamine most common sedative – 62% of patients
• Orthopaedic reduction most common indication – 66%

• SAEs – 69 (1.1%)
  • No complete airway obstruction, aspiration, near injury or death
  • Apnea 55 (0.9%)
  • Laryngospasm 4 (0.1%)
  • Hypotension 7 (0.1%)
  • Bradycardia 3 (0.1%)

• • 1.4% had significant intervention in response to adverse event – positive pressure ventilation
  • Solo ketamine had lowest incidence of SAE (0.4%) and significant intervention (0.9%)
  • Propofol alone and combination ketamine/fentanyl & ketamine/propofol highest incidence of SAE, 3.7, 3.2 and 2.1% respectively
  • Sedation medication was only risk factor significantly associated with SAEs and greatest association was with propofol or combination ketamine/fentanyl & ketamine/propofol
  • Ketamine/fentanyl & ketamine/propofol associated with greater odds of significant intervention.
  • Pre-procedural opioids and laceration repair significant risk factors for significant intervention
• Oxygen desaturation:
  • Ketamine/fentanyl & ketamine/propofol significant association (OR 2.5 & 2.2) compared to ketamine alone
  • Preprocedure opioids, age, lac repair, LP all significantly associated with desaturation
• Vomiting:
  • Ketamine alone or ketamine/fentanyl significantly associated with vomiting (OR 1.9)
  • Preprocedural opioids and laceration repair (OR 1.5 and 1.7)
  • Preprocedural antiemetics decreased odds (OR 0.5)
• Dose:
  • Median ketamine dose 1.5 (1-2) mg/kg
  • Dose not associated with SAE or interventions
  • Was associated with desaturation (OR1.3) and vomiting (OR 1.3)
• Sedation duration & LOS:
  • Propofol shortest sedation duration (median 51mins) and LOS (median 67mins)
  • Ketamine/fentanyl longest sedation duration (177mins) and LOS (132mins)

Bottom Line

• ED procedural sedation of children (certainly in tertiary paeds EDs) is safe with very low incidence of serious adverse events.
• Ketamine alone wins the day with best outcomes
• Combination of ketamine with propofol/fentanyl increases chance of SAE
• If kid is older than 5 years – give them an antiemetic

Jeff Kline is an Emergency Medicine and Thrombosis Physician and Researcher in the USA.

We talked about his research looking at facial expression and emotional response as a way of aiding diagnosis of serious pathology. This helps to inform the classic “sick/not sick” gestalt of EM.

We also thought about burnout and “HALT” – hungry, angry, late /loo, tired.

Buzzing after maternity’s human factors course last week. Asked team if they were HALT = Hungry Angry Late or Tired. It will catch on! pic.twitter.com/j2VpyGDLaW

— NGH P&P Development (@NGHPPD) July 17, 2017

References:

Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting.

Role of physician perception of patient smile on pretest probability assessment for acute pulmonary embolism.

Jeff Kline @klinelab, Andy Neil

HAP6, HAP8

This was recorded at the EMTA meeting in 2017 with Damian Roland a consultant in PEM from Leicester with an interest in all things Med-Ed. He spoke to us about #FOAMed and some cautionary tales!

Chris Connolley, Damian Roland @damian_roland