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Help build my "so there" file

Jeff698

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    I'm building a "so there" file. It is meant as a go-to place to pull articles to give pesky consultants who think history can r/o ACS or that the tilt test is useful for anything other than annoying ER nurses.

    Help me build my file. What papers do you have in your file?

    Thanks and take care,
    Jeff
     

    FoughtFyr

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      These two are great for the clinical features of ACS. Short answers - look out for syncope and nausea/vomiting.

      Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002 Aug;40(2):180-6.

      Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot G; GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004 Aug;126(2):461-9.

      Good for risk stratification of ACS for obs units.

      http://circ.ahajournals.org/cgi/content/full/111/20/2699

      Those are my best "so there" papers.

      - H
       
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      Hard24Get

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        I'm building a "so there" file. It is meant as a go-to place to pull articles to give pesky consultants who think history can r/o ACS or that the tilt test is useful for anything other than annoying ER nurses.

        Help me build my file. What papers do you have in your file?

        Thanks and take care,
        Jeff
        Blood cultures do not change management in hospitalized patients with community-acquired pneumonia.

        Ramanujam P,
        Rathlev NK.
        Department of Emergency Medicine, Boston University Medical Center, Boston, MA, USA. [email protected]
        OBJECTIVES: To determine if blood cultures identify organisms that are not appropriately treated with initial empiric antibiotics in hospitalized patients with community-acquired pneumonia, and to calculate the costs of blood cultures and cost savings realized by changing to narrower-spectrum antibiotics based on the results. METHODS: This was a retrospective observational study conducted in an urban academic emergency department (ED). Patients with an ED and final diagnosis of community-acquired pneumonia admitted between January 1, 2001, and August 30, 2003, were eligible when the results of at least one set of blood cultures obtained in the ED were available. Exclusion criteria included documented human immunodeficiency virus infection, immunosuppressive illness, chronic renal failure, chronic corticosteroid therapy, documented hospitalization within seven days before ED visit, transfer from another hospital, nursing home residency, and suspected aspiration pneumonia. The cost of blood cultures in all patients was calculated. The cost of the antibiotic regimens administered was compared with narrower-spectrum and less expensive alternatives based on the results. RESULTS: A total of 480 patients were eligible, and 191 were excluded. Thirteen (4.5%) of the 289 enrolled patients had true bacteremia; the organisms isolated were sensitive to the empiric antibiotics initially administered in all 13 cases (100%; 95% confidence interval = 75% to 100%). Streptococcus pneumoniae and Haemophilus influenzae were isolated in 11 and two patients, respectively. The potential savings of changing the antibiotic regimens to narrower-spectrum alternatives was only 170 dollars. CONCLUSIONS: Appropriate empiric antibiotics were administered in all bacteremic patients. Antibiotic regimens were rarely changed based on blood culture results, and the potential savings from changes were minimal.
        PMID: 16766742 [PubMed - indexed for MEDLINE]

        Clinical utility of blood cultures in adult patients with community-acquired pneumonia without defined underlying risks.

        Chalasani NP,
        Valdecanas MA,
        Gopal AK,
        McGowan JE Jr,
        Jurado RL.
        Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, USA.
        STUDY OBJECTIVE: We retrospectively examined the clinical utility of obtaining routine blood cultures before the administration of antibiotics in certain nonimmunosuppressed patients with community-acquired pneumonia (CAP) admitted to the hospital during 1991. DESIGN: Retrospective review. SETTING: Grady Memorial Hospital (a county hospital primarily serving inner-city Atlanta). PATIENTS OR PARTICIPANTS: Hospital discharge diagnosis listings identified 1,250 adults ( > or = 18 years old) with pneumonia. From this group of patients, we selected patients admitted to the hospital with (1) respiratory symptoms and a lobar infiltrate on chest radiograph that were present at the time of hospital admission, (2) two or more sets of blood cultures obtained within 48 h of hospital admission, and (3) absence of defined risk factors: HIV-related illness, malignancy, recent chemotherapy, steroid therapy, sickle cell disease, nursing home residence, or hospital stays within the past 14 days. MEASUREMENTS AND RESULTS: Five hundred seventeen patients (mean age, 52 years;: age range, 18 to 103 years) qualified. Of these 517 patients, 25 patients (4.8%) had growth in blood cultures considered contaminants while 34 (6.6%) had blood cultures positive for the following pathogens: 29 Streptococcus pneumoniae, 3 Haemophilus influenzae, and 1 Streptococcus pyogenes, 1 Escherichia coli. Antibiotic therapy was changed for 7 of the 34 patients with positive blood cultures (1.4% of study patients). Antibiotic regimens were altered in 48 additional patients based on sputum culture, poor clinical response, and allergic reactions. CONCLUSIONS: Few blood cultures were positive for likely infecting organisms in adult patients with CAP without defined underlying risk factors. Furthermore, a total of $34,122 was spent on blood cultures at $66 per patient. In this carefully defined group of patients, blood cultures may have limited clinical utility and questionable cost-effectiveness.
        PMID: 7555163 [PubMed - indexed for MEDLINE]

        There should be a "so there" sticky :thumbup:
         

        Jeff698

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          C. J. Swap, J. T. Nagurney. Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes. JAMA 2005;294:2623-2629.

          BTW, I just did the blood Cx in CAP paper in journal club. I agree, a clear cut addition to the So There Files.

          Thanks!

          Take care,
          Jeff
           

          Wahoo

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            Esposito TJ, Ingriham A, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59(6):1314-9.

            From the authors' conclusion: "Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous."



            There are many articles similar to this one, and it is my personal mission to call attention to these before my internship begins in a few months.
             

            bluejay68

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              C. J. Swap, J. T. Nagurney. Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes. JAMA 2005;294:2623-2629.

              BTW, I just did the blood Cx in CAP paper in journal club. I agree, a clear cut addition to the So There Files.

              Thanks!

              Take care,
              Jeff



              That Swap paper is from a current PGY-2 EM resident at the Brigham/MGH program (Cliff Swap).



              Here are some others that I find myself using frequently:

              Rivers' Early Goal Directed Therapy paper (most people know this, but you still get some Medicine residents who ask about why you transfused with a HCT of 29 or didn't start pressors earlier)
              http://content.nejm.org/cgi/content/abstract/345/19/1368

              PIOPED II (why patients with very high clinical suspicion of PE and a negative PE-protocol chest CT may need to be admitted for a VQ scan)
              http://content.nejm.org/cgi/content/full/354/22/2383

              New Orleans Criteria and Canadian Head CT rules (back up for not scanning a head during passoff or backup for ordering a head CT with the radiologist)
              http://content.nejm.org/cgi/content/short/343/2/100
              http://linkinghub.elsevier.com/retrieve/pii/S014067360004561X

              NEXUS c-spine criteria (backup for scanning or not scanning a c-spine)
              Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR, for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. July 2001;38:17-21
               

              mikecwru

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                Blood cultures do not change management in hospitalized patients with community-acquired pneumonia.
                PMID: 16766742

                There should be a "so there" sticky :thumbup:


                You have a two sided fight with blood cultures in pneumonia; several IDs love them and more importantly, you will be dinged by JCAHO for not ordering them on admitted patients. They are not science based.

                mike
                 

                Jeff698

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                  You have a two sided fight with blood cultures in pneumonia; several IDs love them and more importantly, you will be dinged by JCAHO for not ordering them on admitted patients. They are not science based.

                  Yes, this is true. But at least with this paper in hand (and many others showing the same thing) you can at least be smug about it as you order the cultures anyway.

                  Sort of how I feel when I ask my nurse to do a tilt test on the GI bleeded. Do I know it's crap? Yes. Does the nurse know it's crap? Yes. Does the medicine intern care? No. All he knows is that he'll be asked about it in the morning and he'd better have the answer.

                  Take care,
                  Jeff

                  Thanks for all the papers. Keep 'em coming. The file grows by the minute!
                   

                  FISKUS

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                    1: Ann Emerg Med. 2004 Nov;44(5):454-9. Links
                    Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related?Roback MG, Bajaj L, Wathen JE, Bothner J.
                    Department of Pediatrics and Section of Emergency Medicine, University of Colorado School of Medicine, Denver, CO, USA. [email protected]

                    STUDY OBJECTIVE: Fasting time before procedural sedation and analgesia in a pediatric emergency department (ED) was recently reported to have no association with the incidence of adverse events. This study further investigates preprocedural fasting and adverse events. METHODS: Data were analyzed from a prospectively generated database comprising consecutive sedation events from June 1996 to March 2003. Comparisons were made on the incidence of adverse events according to length of preprocedural fasting time. RESULTS: Two thousand four hundred ninety-seven patients received procedural sedation and analgesia. Four hundred twelve patients were excluded for receiving oral or intranasal drugs (n=95) or for receiving sedation for bronchoscopy by nonemergency physicians (n=317). A total of 2,085 patients received parenteral sedation by emergency physicians. Age range was 19 days to 32.1 years (median age 6.7 years); 59.9% were male patients. Adverse events observed included desaturations (169 [8.1%]), vomiting (156 [7.5%]), apnea (16 [0.8%]), and laryngospasm (3 [0.1%]). Fasting time was documented in 1,555 (74.6%) patients. Median fasting time before sedation was 5.1 hours (range 5 minutes to 32.5 hours). When the incidence of adverse events was compared among patients according to fasting time in hours (0 to 2, 2 to 4, 4 to 6, 6 to 8, >8, and not documented), no significant difference was found. No patients experienced clinically apparent aspiration. CONCLUSION: No association was found between preprocedural fasting and the incidence of adverse events occurring with procedural sedation and analgesia.
                     

                    WilcoWorld

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                      This is arguably (no pun intended) the best thread I've ever seen on this forum.

                      I think it would be a good idea for people to follow the lead of FISKUS and post abstracts along with their ammo, I mean, references.

                      thanks
                       

                      Hard24Get

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                        This is arguably (no pun intended) the best thread I've ever seen on this forum.

                        I think it would be a good idea for people to follow the lead of FISKUS and post abstracts along with their ammo, I mean, references.

                        thanks


                        ok, good point - I updated mine above

                        Emergency medicine residents effectively direct inhospital cardiac arrest teams.

                        Adams BD,
                        Zeiler K,
                        Jackson WO,
                        Hughes B.
                        Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX 78234-6200, USA. [email protected]
                        STUDY OBJECTIVE: We compared 2 models of physician leadership for inhospital cardiac arrest teams (CATs): emergency medicine (EM) residents and staff hospitalist physicians. METHODS: A before-after study was conducted on all adult inhospital CAT activations over a 2-year period. The primary outcome was return of spontaneous circulation (ROSC). RESULTS: There were 749 total code blues during the 2-year study period. Ninety-one were excluded by protocol. EM residents directed 288 codes, hospitalists directed 248 codes, and other specialties directed the remaining 62. There was no statistically significant difference in percent ROSC or survival to hospital discharge. EM residents responded first for 59.2% of the codes compared with a first response rate of 28% for hospitalists (P<.05). Time to achieve ROSC was quicker in the EM resident cohort. CONCLUSION: Our findings validate the use of a 24-hour EM resident staffing model for CAT response to inhospital cardiac arrests.
                        PMID: 15915402 [PubMed - indexed for MEDLINE]
                         
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                        BADMD

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                          http://linkinghub.elsevier.com/retrieve/pii/S014067360004561X

                          NEXUS c-spine criteria (backup for scanning or not scanning a c-spine)
                          Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR, for the NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. July 2001;38:17-21

                          NEXUS criteria kind of scare me. I had a patient who had a very minor trauma and was NEXUS negative, but didn't just didn't sit right with me. He had some weird lateral neck tenderness and couldn't turn his neck (Go CCR). I CTed his neck and he had a C3 pedicle fracture, a unilateral locked facet and had pinched off his vertebral artery (but the distal portion was reconstructed by collaterals). Then I found this paper: Ian G. Stiell, M.D., M.Sc., Catherine M. Clement, R.N., R. Douglas McKnight, M.D. et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. NEJM December 25, 2003. Volume 349:2510-2518. Bottom line is that NEXUS was only 90.7% sensitive. **Gulp**
                           

                          bulgethetwine

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                            Good for laughter: The nurse who freaks out when I order more than 4 mg of morphine at one time (which is why I more often use Dilaudid as curiously 2mg doesn't cause them to think twice) and the internal medicine resident who orders morphine in 2mg aliquots.

                            Ammo for why you can laugh smugly:

                            Intravenous morphine at 0.1 mg/kg is Not Effective for Controllling Severe Acute Pain In the Majority of Patients
                            Bijur, Kenny, Gallagher
                            Annals 46(4) Oct 2005 362-367
                             

                            doctawife

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                              Good for laughter: The nurse who freaks out when I order more than 4 mg of morphine at one time (which is why I more often use Dilaudid as curiously 2mg doesn't cause them to think twice) and the internal medicine resident who orders morphine in 2mg aliquots.

                              Ammo for why you can laugh smugly:

                              Intravenous morphine at 0.1 mg/kg is Not Effective for Controllling Severe Acute Pain In the Majority of Patients
                              Bijur, Kenny, Gallagher
                              Annals 46(4) Oct 2005 362-367

                              Okay, this is the point where I'm supposed to supply more evidence.

                              I'm not gonna do that, I can say that for pediatric sicklers, 0.1 mg/kg barely cuts it.
                               

                              Febrifuge

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                                Umm... that is an extremely vague question.

                                Helpful for what, specifically? Help us help you. Is there a "so there"-style point you'd like to be able to prove or argue (e.g., the rest of the thread)? Or is there a general realm of pediatric problems you're looking to address?
                                 
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                                Painter1

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                                  Good for laughter: The nurse who freaks out when I order more than 4 mg of morphine at one time (which is why I more often use Dilaudid as curiously 2mg doesn't cause them to think twice) and the internal medicine resident who orders morphine in 2mg aliquots.

                                  Ammo for why you can laugh smugly:

                                  Intravenous morphine at 0.1 mg/kg is Not Effective for Controllling Severe Acute Pain In the Majority of Patients
                                  Bijur, Kenny, Gallagher
                                  Annals 46(4) Oct 2005 362-367

                                  I had an otherwise healthy lady drop her bp from 120/70 to 80/40 with 5mg of morphine IVP. she came up with a liter bolus and bp increased porportinately with the size of her pupils. i have no other explanation for her drop in bp which was personally taken by me on separate arms multiple times.
                                   

                                  Hard24Get

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                                    Paper courtesy of ERMudPhud showing that EPs account for significantly less malpractice indemnity than non-EM residency-trained physicians, ie are approximately half as likely to be "proven" clinically inappropriate in court.

                                    Branney SW, Pons PT, Markovchick VJ, Thomasson GO.
                                    Malpractice occurrence in emergency medicine: does residency training make a difference?
                                    J Emerg Med. 2000 Aug;19(2):99-105.
                                    PMID: 10903454 [PubMed - indexed for MEDLINE]
                                     

                                    bulgethetwine

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                                      I had an otherwise healthy lady drop her bp from 120/70 to 80/40 with 5mg of morphine IVP. she came up with a liter bolus and bp increased porportinately with the size of her pupils. i have no other explanation for her drop in bp which was personally taken by me on separate arms multiple times.

                                      At the risk of replying to an old post, the problem is so rare that I would prefer to have to give the intervention you did to this lady 1 time out of... what, 200? then to nurse *every* patient along with 2mg aliquots. Regardless of the dose I give, I watch closely to be able to intervene as you did.
                                       

                                      I am Hans

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                                        Not really relevant for ED, but given the comment above that "goal directed therapy" supports transfusion to normal or supernormal levels (the study wasn't designed for that), I often use the articles below for information regarding a "restrictive transfusion policy" and why we don't automatically tranfuse to 10 & 30 anymore:

                                        J Trauma. 2004 Sep;57(3):563-8; discussion 568.
                                        Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients?
                                        McIntyre L, Hebert PC, Wells G, Fergusson D, Marshall J, Yetisir E, Blajchman MJ; Canadian Critical Care Trials Group.

                                        N Engl J Med. 1999 Feb 11;340(6):409-17.
                                        A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. (the TRICC trial)
                                        H&#233;bert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E.

                                        Crit Care Med. 2004 Jan;32(1):39-52.
                                        The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States.
                                        Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, MacIntyre NR, Shabot MM, Duh MS, Shapiro MJ.
                                         

                                        leviathan

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                                          I had an otherwise healthy lady drop her bp from 120/70 to 80/40 with 5mg of morphine IVP. she came up with a liter bolus and bp increased porportinately with the size of her pupils. i have no other explanation for her drop in bp which was personally taken by me on separate arms multiple times.

                                          Try diphenhydramine with the bolus next time, assuming there is a next time.
                                           
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                                          Chartres

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                                            Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.

                                            Cardall T, Glasser J, Guss DA. Acad Emerg Med. 2005 May;12(5):480; author reply 480-1.

                                            *Back up for admitting possible appy to surgery with normal WBC, or admitting without ordering a WBC
                                             

                                            Smashweasel

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                                              Im a med student getting ready to do an away EM rotation and was looking for some advice on what studies should I definitely know something about. Ive been looking over some of the above, but any additional input would be greatly appreciated.
                                               

                                              irrka

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                                                how about something about sono dx of appy? i had a girl with a definite appy on the sonogram, only to be told by a surg resident that he "doesn't believe in ultrasound" and she needs a CT "to find out what if she has an abscess" (the fact that neither of those sentences make any sense seemed to be lost on him and he ignored my asking him to speak to his attending first--who strangely enough "believes" if a study is positive it's positive)
                                                 

                                                kungfufishing

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                                                  how about something about sono dx of appy? i had a girl with a definite appy on the sonogram, only to be told by a surg resident that he "doesn't believe in ultrasound" and she needs a CT "to find out what if she has an abscess" (the fact that neither of those sentences make any sense seemed to be lost on him and he ignored my asking him to speak to his attending first--who strangely enough "believes" if a study is positive it's positive)

                                                  I think this is a hard topic to put together a convincing study on due to the heterogeneity of operators. I don't doubt your scan, but you are asking someone to go cut open a belly, even if they are lap holes.
                                                   

                                                  southerndoc

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                                                    I think this is a hard topic to put together a convincing study on due to the heterogeneity of operators. I don't doubt your scan, but you are asking someone to go cut open a belly, even if they are lap holes.
                                                    In today's society, it's hard to justify a negative appy diagnosed in the OR. Likewise, it would be extremely difficult to defend any complications of the surgery if the appendix was normal. (More trouble than defending it if the person actually had appendicitis.)

                                                    We have some great surgeons where I practice who will take people to the OR based on clinical exam during the day. During the night, or if you're a female, you pretty much get a CT to make sure it's your appendix and not your ovary. Just two days ago one of our surgeons took a 22-year-old to the OR based on clinical exam. He said he would do it more often if my colleagues in the ER didn't always call him so late in the course. He said usually by the time he gets the call, the person has already had the CT scan.

                                                    It's my experience that appendicitis with an abscess is handled differently. Antibiotics and percutaneous drainage done by IR first.
                                                     

                                                    irrka

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                                                      I think this is a hard topic to put together a convincing study on due to the heterogeneity of operators. I don't doubt your scan, but you are asking someone to go cut open a belly, even if they are lap holes.

                                                      I was talking about an official sono read by radiologist. My own sonos don't count for jack except FAST and own education
                                                       

                                                      docB

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                                                        RxnMan

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                                                          "Projected Cancer Risks From Computed Tomographic Scans Performed in the United States in 2007", Berrington de Gonzalez, Arch Intern Med. 2009;169(22):2071-2077

                                                          Table 1 has the rates of calculated lifetime cancer risk attributable to CT scanning, broken down by age at scan and type of scan.

                                                          And bump!
                                                           

                                                          Peter Parker

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                                                            For the next time someone demands a line "up top to measure a CVP" ...

                                                            Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares.

                                                            Marik PE, Baram M, Vahid B.

                                                            Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, 834 Walnut St, Suite 650, Philadelphia, PA 19107, USA. [email protected]

                                                            Comment in:

                                                            * Chest. 2008 Dec;134(6):1352; author reply 1352-3.
                                                            * Chest. 2008 Dec;134(6):1351-2; author reply 1352-3.

                                                            BACKGROUND: Central venous pressure (CVP) is used almost universally to guide fluid therapy in hospitalized patients. Both historical and recent data suggest that this approach may be flawed. OBJECTIVE: A systematic review of the literature to determine the following: (1) the relationship between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the ability of the change in CVP (DeltaCVP) to predict fluid responsiveness. DATA SOURCES: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Study selection: Reported clinical trials that evaluated either the relationship between CVP and blood volume or reported the associated between CVP/DeltaCVP and the change in stroke volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, healthy control subjects, and ICU and operating room patients. DATA EXTRACTION: Data were abstracted on study design, study size, study setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or receive operator characteristic [ROC]) between CVP/DeltaCVP and change in stroke index/cardiac index, percentage of patients who responded to a fluid challenge, and baseline CVP of the fluid responders and nonresponders. Metaanalytic techniques were used to pool data. DATA SYNTHESIS: The 24 studies included 803 patients; 5 studies compared CVP with measured circulating blood volume, while 19 studies determined the relationship between CVP/DeltaCVP and change in cardiac performance following a fluid challenge. The pooled correlation coefficient between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28). Overall, 56+/-16% of the patients included in this review responded to a fluid challenge. The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled correlation between DeltaCVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7+/-2.32 mm Hg [mean+/-SD] in the responders as compared to 9.7+/-2.2 mm Hg in nonresponders (not significant). CONCLUSIONS: This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.

                                                            PMID: 18628220

                                                            Chest. 2008 Jul;134(1):172-8.
                                                             

                                                            Winged Scapula

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                                                              In today's society, it's hard to justify a negative appy diagnosed in the OR. Likewise, it would be extremely difficult to defend any complications of the surgery if the appendix was normal. (More trouble than defending it if the person actually had appendicitis.)

                                                              We have some great surgeons where I practice who will take people to the OR based on clinical exam during the day. During the night, or if you're a female, you pretty much get a CT to make sure it's your appendix and not your ovary. Just two days ago one of our surgeons took a 22-year-old to the OR based on clinical exam. He said he would do it more often if my colleagues in the ER didn't always call him so late in the course. He said usually by the time he gets the call, the person has already had the CT scan.

                                                              It's my experience that appendicitis with an abscess is handled differently. Antibiotics and percutaneous drainage done by IR first.

                                                              Actually, patients should always be told that there exists an approximate 10% - 20% rate of negative appys but that the risk of perforated appendicitis is higher than the operative risks.

                                                              The widespread use of CT scans has lowered that rate in many studies but, speaking from experience, I've found positive appys with negative CTs and positive CTs with negative appys (the latter of which are especially frustrating because once you have a "positive" reading, even if the clinical exam is negative, you're essentially obligated, for potential litigation reasons, to operate).

                                                              And yes, perforated appys are almost always treated now with ABX and drain placement with interval appy several weeks later. Going into that belly is a nightmare at the time of perf.
                                                               
                                                              Last edited:

                                                              Emedpa

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                                                                I can't find the study right now but there was one a few years ago showing oral contrast added nothing to IV contrast in making the diagnosis of appendicitis or diverticulitis in adults when newer generation scanners were used.
                                                                we hardly ever use oral contrast anymore in my dept in adults unless they are very thin.
                                                                this has cut significant time off lengths of stay in the e.d. as the 2 or 3 hr oral preps are a thing of the past in the vast majority of cases now. most of the younger radiologists are on board with this now but we still have a few older guys who complain( until we ask if we need to find someone else who is comfortable reading the study...).
                                                                 

                                                                PaddyofNine

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                                                                  I'd love to find some bit of evidence that I could wield when being bleeped at 4am to come and culture some spiking patient on the wards because the team wrote down "culture if spikes" earlier. I always claim they'll still be bacteriaemic at 6am, but not many nurses buy it. I could only find one paper to back up my claim:

                                                                  "The Timing of Specimen Collection for Blood Cultures in Febrile Patients with Bacteremia" - Riedel et al, Journal of Clinical Microbiology, February 2008

                                                                  Anyone else know of any evidence?
                                                                   

                                                                  RxnMan

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                                                                    Dr Michelle Lin of UCSF has been producing a set of referenced clinical algorithm cards which can be found here. These are free to print off and distribute. The latest covers the clinical features of patients that determine when you should be able to skip the CT before LP in suspected menigitis (attached).

                                                                    I thought these might help the ol' "So there!" file :thumbup:
                                                                     

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                                                                    in1Q84

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                                                                      These two are great for the clinical features of ACS. Short answers - look out for syncope and nausea/vomiting.

                                                                      Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002 Aug;40(2):180-6.

                                                                      Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, Montalescot G; GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004 Aug;126(2):461-9.

                                                                      Good for risk stratification of ACS for obs units.

                                                                      http://circ.ahajournals.org/cgi/content/full/111/20/2699

                                                                      Those are my best "so there" papers.

                                                                      - H

                                                                      Thank you. These are great!
                                                                       

                                                                      deuist

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                                                                        Zielinski MD, et. Small bowel obstruction-who needs an operation? A multivariate prediction model. World J Surg. 2010 May;34(5):910-9.

                                                                        Free intraperitoneal fluid, mesenteric edema, lack of the "small bowel feces sign," and a history of vomiting were independent predictors of the need for operative exploration. The combination of the four had a sensitivity of 96%, and a positive predictive value of 90% (OR 16.4, 95% CI 3.6-75.4) for requiring exploration.

                                                                        Ischemia was associated with peritonitis, free intraperitoneal fluid, elevated serum lactate concentration, mesenteric edema, closed loop obstruction, pneumatosis intestinalis, and portal venous gas.
                                                                         

                                                                        deuist

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                                                                          I'm also looking for two papers. One that discredits DRE's for occult blood testing (does it really matter if the guaiac was positive?) and another for neutropenic patients. I know lots of guidelines and textbooks mention neutropenia and thrombocytopenia as contraindications for rectal exams, but I can't find an actual paper that proves it.
                                                                           
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