February 2020

Authors:

– Andy Neill
– Brendan McGrath

Brendan is a Consultant in Anaesthesia and Intensive Care Medicine and Honorary Senior Lecturer, Manchester University Hospital NHS Foundation Trust.

His work has focussed on management of tracheostomy emergencies. There are lots of great resources available over on the website

Of particular use are the two algorithms for emergency management

Trachesotomy emergency management

Laryngectomy emergency management.

This month Chris and Becky are looking at Pneumonia and the NICE guidelines which were updated in 2019.

Pneumonia is a common problem affecting 0.5-1% of the population per year.
Of those admitted to hospital the mortality can be up to 14% or in ICU can be as high as 30%.

CURB65 remains the go to for risk stratification in patients in ED BUT must be coupled with clinical assessment of the patient as a whole!
Score 0-1 = low risk = 3% mortality risk
Score 2 = Intermediate risk = 3-15% mortality
Score 3 = High risk = >15% mortality risk and recommend ICU admission.

The guideline reminds Chris and Becky to be more proactive in looking for sputum cultures and sending urinary antigens for legionella and pneumococcus.

Treatment should follow local microbiology intelligence on pathogens and resistance patterns but reminds us that even in those admitted patients remember that oral antibiotics are good enough for many!!

Authors:

– Andy Neill
– Brendan McGrath

Brendan is a Consultant in Anaesthesia and Intensive Care Medicine and Honorary Senior Lecturer, Manchester University Hospital NHS Foundation Trust.

His work has focussed on management of tracheostomy emergencies. There are lots of great resources available over on the website

Of particular use are the two algorithms for emergency management

Trachesotomy emergency management

Laryngectomy emergency management.

Clinical Question:

Can YEARS be used to safely avoid imaging pregnant women with suspected PE?

Title of Paper:

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Journal and Year:

NEJM. 2019.

Lead Author:

van de Pol

Background:

* YEARS:
* Clinical signs of DVT
* Haemoptysis
* Coughing up small amounts or a streak of blood
* PE most likely
* Wells’ et al. style

Study Design:

* Multicentre, international study – 18 hospitals

Patients Studied:

Inclusion:

* Pregnant patients >18 years of age
* Referred to ED or obstetrics with ?PE
* New onset/worsening of chest pain / dyspnea
* ± haemoptysis
* ± tachycardia

Exclusion:

* Already on treatment dose anti-coagulation >24 hours prior
* Unavailability for follow up
* Allergy to contrast
* Life expectancy of < 3 months

What did they do?

* YEARS criteria applied to included patients
* ?DVT → DVT US
* +ve → presumed PE → treated
* -ve → continue PE workup with D-Dimer
* YEARS +ve – D-Dimer threshold set at 500
* ≥ 500 → CTPA
* <500 → PE excluded
* YEARS -ve – D-Dimer threshold set at 1000
* ≥ 1000 → CTPA
* < 1000 → PE excluded

Follow up:

* If PE excluded patients followed up for 3 months for occurrence of symptomatic VTE

Outcomes:

Primary:

* Cumulative incidence of VTE during 3 month follow up
* CTPA
* Death from PE
* On PM
* No other cause identified
* Proximal DVT

Secondary:

* Proportion of patients in whom CTPA was not indicated to safely rule out PE
* Compared to hypothetical situation in which all patients would have had CTPA or VQ scan

Summary of Results:

* 510 patients → 498 included
* Third trimester 46%
* Previous VTE 6%
* Thrombophilia 2.8%
* YEARS -ve 51%
* YEARS +ve (at least one) 49%
* Haemoptysis 7.7%
* Clinical signs DVT 19% (47 patients)
* 3 patients +ve on US (7%)
* 79 patients who didn’t clinically have DVT also got compression US
* 1 (1%) +ve – also was YEARS +ve for likely PE and had D-Dimer 1480
* PE most likely 89% (no surprise there)

* 494 patients once confirmed DVTs excluded
* -ve D-Dimer in 195 (39%)
* +ve D-Dimer in 299
* 2 got VQ
* 273 got CTPA
* 24 didn’t get imaged (protocol violation)
* PE confirmed in 16 patients
* 1 had -ve YEARS but +ve D-Dimer
* 15 had +ve YEARS and +ve D-Dimer
* PE +ve at baseline = 20 patients (4%)

Primary:

* 477 patients with PE initially excluded
* 1 diagnosed with VTE on follow up
* YEARS -ve, D-dimer 480
* Symptomatic popliteal DVT on US on day 90 of follow up period
* No PEs diagnosed
* Worst case scenario including all patients lost to follow up:
* Incident of VTE at 3 months would be 0.42% (CI 0.11 – 1.5)

CTPA avoided in:

* 39% of patients overall
* 65% of patients in first trimeter
* 46% of patients in second trimester
* 32% of patients in third trimester

Authors Conclusion:

The pregnancy-adapted YEARS diagnostic algorithm safely ruled our acute pulmonary embolism in pregnant patients who were referred for suspected pulmonary embolism. The main advantage of this approach was that CTPA was averted in 32 – 65% of the patients, depending on trimester of presentation, without compromising safety.

Clinical Bottom Line:

Its a positive and pragmatic concept, but the numbers are small and the PE prevalence low – is it ready for action? As with all of these I think it really adds to your overall clinical decision making rather than handing us absolutes. I’ll probably use it for shared decision making with the patient as much as anything.

Other #FOAMed Resources / References:

Dan Horner covered all things PE in St. Emlyn’s Journal club, April this year