May 2020

Author: Mark Winstanley / Codes:  / Published: 01/04/2020

 

Author: Michelle Tipping

This podcast focuses on a slightly different CPD topic which is not only relevant to current circumstances but will also be very relevant to us all once life returns to some semblance of normality: resilience & leadership.

Dan is a former Military Officer who spent 16 years in the Army. Most of his career was spent serving with the SAS, the Army’s elite Special Forces Regiment. He now runs a consultancy firm Metris Leadership who have worked with major businesses and healthcare trusts such as Great Ormond Street Hospital.

Have a look at their website for lots of blogs and inspirational reading ideas regarding leadership and resilience. Dan has kindly given his time for free today but if you like what you hear please keep Metris Leadership in mind for training days in the future.

Resources:

metrisleadership.com

Authors

Andy Neill
Dave McCreary

Clinical question:

– should we be using longer cannulas for US guided peripheral IVs?

Paper

– Ultralong Versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasonographically Guided Catheter Survival

Author:

– Bahl, 2020, Annals EM

Background:

– US has had a huge impact on the ability to place IVs in difficult access patients with the minimal number of attempts. I suspect that we in EM do this more than anyone else in the hospital. However the recurring theme is that you get the cannula in, it flushes fine, they get their first dose of antibiotics then an hr later it’s dislodged when they moved their arm.
– in a previous hospital someone managed to track down longer standard cannula (60mm instead of the standard 45mm green or 32 mm pink). Anecdotally i felt this helped.

Methods:

– single site non blinded RCT in the states.
– compared a 48mm 20 gauge to a 63mm 20 gauge
– convenience sample with self reported vascular access (my concern would be this is like self reported “high pain threshold)
– importantly had trained research staff do the follow up rather than depending on patchy ad hoc follow up of the cannula
– staff placing could be anywhere from consultants to “technicians”. (This drives me crazy – why aren’t we doing this, why don’t we train the health care assistants or other staff to do this. It is not a skill that needs a doctor’s salary!)
– they do not mention the level of sterility used in placement (which i think is an important unanswered question)
– primary end point was duration of catheter survival

results

– 250 patients
– 5.7 days v 3.9 days favouring the long group

Thoughts

– get yourself some longer cannulas
– I would still love a clear answer to the level of sterility required for this. The longer cannulas remain functional the more chance they have for infection and maybe we need a stricter attention to sterility for deeper peripheral IVs that are going to stay in for longer.

Reading:
St Emlyns
EMCRIT
Kylie Baker tips video

This month Becky and Chris turn their attention to all things AKI in the guidelines section and take us through NICE guideline 148 on the topic. 

First up we need to define AKI.

1: A rise in serum Creatinine by 26 micromol/L or more in 48hours
2: A 50% rise in creatinine known or presumed to have happened in the last 7 days.
3: A fall in Urine Output to <0.5mls/kg/hr for 6 hours in adults.
4: A 25% or greater drop in eGFR in children or young people in the last 7 days

Testing needs to be focused and care bundles can be really useful here.

Urinalysis: Look for protein, blood, Nit and glucose. Make sure you document the result!
Ultrasound: If suspected infected/obstructed kidney then this should be done within 6 hours of suspected diagnosis. If there is no other cause identified for the AKI then an US should take place within 24 hours.

Onward referral to urology should be made if there is an obstructed cause identified, and immediately if there’s a single kidney, bilateral obstructions, or pyeonephrosis.

Referall for renal replacement therapy (RRT) should take place if there is no response to treatment in the following circumstances
1: Hyperkalaemia
2: Metabolic acidosis
3: Uraemic complications such as pericarditis, encephalopathy
4: Fluid overload

Remember to involve the renal docs early if there is an AKI in patients who have had a renal transplant!

NICE supports a ‘no delay’ for Emergency CT scanning with IV contrast but does urge caution in higher risk groups if considering non-emergency scanning.
These are older patients, diabetics with CKD, those witrh an eGFR <40 and heart failure patients.

As always let us know if you have an y comments on the podcast or anything you want us to cover in the guidelines section!!

Refs:
www.nice.org.uk

Authors:

Andy Neill
Dave McCreary

Clinical Question

– should we cool non shockable rhythms post cardiac arrest?

Study

Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm

Author

– Lascarrou, NEJM 2019

Background

– the two original trials from Europe and Australasia into therapeutic hypothermia only included shockable rhythms. These were both +ve trials and so for a while we all got very excited about cooling to 32-34 degrees for post arrest patients. Even though the trials didn’t include non shockable rhythms we still did it for everyone
– then the TTM trial came along in 2013 and included some non shockable rhythms. It suggested that the key was avoiding fever rather than cooling itself. So we’re left with the ILCOR recommendations of the broad range of 32-36 but still not great data on non shockable rhythms.

Methods

– otherwise known as HYPERION trial (no link to the Dan Simmons book…)
open label, blinded outcome assessor multicentre RCT
– 25 ICUs in France
– could be in or out of hospital arrests of any cause as long as they were non shockable
– excluded folk in whom it looked like they were just dying
– interestingly because both interventions are within standard of care they didn’t need consent to randomise but bizarrely they did need consent to look at their data due to data protection law.
– randomised at ICU admission to a target temp of 33 v 37 degrees. 33 degree group were aimed to be at target for 24 hrs then slowly rewarmed with intervention period stopping at the 48 hr mark
– they say they did neuroprognostication according to guidelines but they’re not explicit as to whether that means they did the full 72 hrs on everyone
– outcome was favourable neuro survival at 90 days which is just the kind of outcome we like to see. The downside is that this outcome was assessed by a single psychologist over the phone
– They somewhat optimistically thought 33 degrees would lead to an absolute improvement in primary outcome of 9%

Results

– 2700 screened and 584 randomised
– 80% asystole!! with half asphyxia (i suspect that means hanging…) and a quarter cardiac cause.
– ~4hrs from arrest to randomisation (so this is not an early intervention trial)
– a quarter were in hospital (who are very different from what we’re used to)
– mainly surface cooled with a variety of devices
– good neuro outcome was 10% v 6% favouring 33 degrees (4.5% difference, CI 0.1-8.9)
– mortality was pretty much the same both groups
– pics in the paper suggest good “dose delivery” of the assigned treatment

Thoughts

– important data that suggests cooling is more important in the non shockable cardiac arrest population
– the open label may well be the big issue here as ultimately these people only die in these trials when we withdraw life sustaining therapy. in their supplementary material it looks like they let both groups go the same distance before pronosticating but we know that cooling can make a difference to prognostication. It might be as simple as we tried harder for longer in the cooled group.
– the other fly in the ointment is the stats. they were fishing for a 9% difference assuming a much higher survival. They found a much smaller difference with a much lower overall survival. Turns out it’s “statistically significant” but you’d be wise not to put too much weight on that.

Further Reading:
REBEL EM
PulmCrit

2 Comments

  1. suresh kumart says:

    informative, quick revision for aki, hypothermia

  2. alsalimw says:

    Excellent way of getting updated knowledge

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