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Date: December 21st, 2014

Guest Skeptics: Dr. Chris Bond. Chris is a clinical lecturer and emergency physician at the University of Calgary, creator of the SOCMOB blog, dogma basher, and wine/food super geek. Chris appeared on SGEM#86 (Achy Breaky Heart) discussing colchicine as a very effective treatment for acute pericarditis.

Dr. Teresa Chan. Teresa is an Assistant Professor at McMaster University and her research focuses on a number of different areas including: 1) Competency Assessments and Modeling in Residency Education and 2) Social Media Teaching & Learning. She is the co-editor for the Canadian Association of Emergency Physicians (CAEP) Feature Education Innovations (FEI) series.

This is going to be the second SGEM-HOP (Hot Off the Press) episode. Usually we are trying to cut the knowledge translation window down from over ten years to less than one year. The SGEM-HOP cuts that KT window down to less than one week. This is done by getting copies of an important Emergency Medicine manuscript prior to publication. Then we do a structured critical review using a method that has been shown to be validated and reliable.

The first SGEM-HOP (SGEM#89) on geriatric falls with Dr. Chris Carpenter was a huge success. One interesting finding from that systematic review was that the inability to cut one’s own toenails had the best negative likelihood ratio for 6-month fall risk. The SGEM bottom line from the fist SGEM-HOP was “We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.”

This second SGEM-HOP is going to be a special one given the holiday season. We used the British Medical Journal (BMJ) holiday edition as inspiration. Each year the BMJ publishes some very entertaining research studies. One of my favourite ones was the Parachute Trial. It was a systematic reviewed looking at whether or not parachutes could prevent death and major trauma related to gravitational challenges?

The SGEM has actually done a few PUB Casts on a couple of BMJ Holiday Edition articles. The first one (SGEM#6) reviewed the study called Orthopedic Surgeons: As Strong as an Ox and almost Twice as Clever? Multi-Centre Prospective Comparative Study. Subramanian et al. BMJ 2011. Their conclusions: “Male orthopedic surgeons have greater intelligence and grip strength than their male anesthetic colleagues, who should find new ways to make fun of their orthopedic friends.”

The other study done as a PUB Cast (SGEM#23) from the BMJ holiday issue was called Pain over Speed Bumps in Diagnosis of Acute Appendicitis: A Diagnostic Accuracy Study. BMJ 2012. Reported pain over a speed bump on the way to the emergency department had a sensitivity of 97% and specificity of 30%. Lack of pain over a speed bump had the best negative likelihood ratio of 0.

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Date: December 15th, 2014

Guest Skeptics: Dr. Stella Yiu. Stella is an Associated Professor at the Department of Emergency Medicine and a Distinguished Teacher at the University of Ottawa.  Her interests include resuscitation and curriculum delivery in medical education.  She is particularly keen to use social media and technology as tools to teach. Stella runs an amazing FlippedEM Classroom for the clerkship program in Ottawa.

Dr. Rob Rogers, otherwise known as Darth Educator,  runs the iTeachEM blog and podcast and director of the Teaching Course. Along with a good friend, Dr. Salim Rezaie, started an educational think tank called the Teaching Institute. Rob is moving in to the University of Kentucky in March of 2015 to join the Department of Emergency Medicine. He will be full Professor and Vice Chair of Faculty Development.

This episode is a SGEM Xtra. A sweet/FOAMy treat for listeners before the holidays. While the goal of the SGEM remains to cut the knowledge translation window down from over ten years to less than one year, this will not be a structured critical review of a recent paper. This episode will discuss ten questions about the Flipped Classroom concepts. Rob and Stella take turns answering the questions from their perspective and experience.

Five (x2) Questions about the Flipped Classroom:

* Define the Flipped Classroom?

* Provide a brief history of the Flipped Classroom?

* Contrast the Flipped Classroom to a traditional model of medical educations?

* Why should we do this, is it just another education fad?

* How hard is it to do a Flipped Classroom?

* How do you select classes to flip and give me an example of a class you have flipped?

* How do you find good Flipped Classroom core content?

* Can you give some references/evidence that this Flipped Classroom works?

* What are some of the  limitations of the Flipped Classroom?

* What lessons have you learned about the Flipped Classroom teaching method?

For more information about the Flipped Classroom there is an excellent guest blog by Dr. Javier Benitez in Academic Life in Emergency Medicine (ALiEM). The title of his post is “Where is the pedagogy in flipped classrooms?”. Javier defines pedagogy, discusses the Flipped Classroom method and provides multiple references and examples.

Stella describes how things are going in Ottawa with her Flipped Classroom initiative. Rob tells us about how the reception has been from participants at his Teaching Course.

Conferences:

I will be the tract chair “Seeking the Truth” at the Social Media and Critical Care (...

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Date: December 13th, 2014

Guest Skeptic: Marcus Prescott is a nurse from Norway. He works at the Trondheim University Hospital. His college thesis was called “Barriers and Facilitators to the implementation of evidence based practice among RNs in specialist health care”. Marcus is also a proud member of the Norwegian Skeptics’ Society and runs their Skeptics in the Pub events.

Case: 25 year-old nurse with no significant past medical history presents to the emergency department with a 48 hour history of aching all over, fever and cough. He did not get a flu shot this year. You diagnose him with a flu like illness and provide him with advice on management and set expectations. However, before leaving the emergency department he wants to know if taking one of those flu drugs he sees on the television will help?

Background: Influenza is a seasonal phenomenon and we have covered the flu before on SGEM#20 Hit Me with Your Best Shot when we discussed mandatory immunization for healthcare workers.

Immunization has been on of the most significant advances in modern medicine. Some vaccines have been highly successful (Haemophilus Influenzae B, small pox, polio) while others have been not as successful (HIV).  Some vaccines work well but are their effectiveness decreases with time (whooping cough).

The flu vaccine is one that is not highly effective. There are a number of reasons it is not as effective. However, there was a Cochrane review showed that vaccinating healthcare workers, in addition to other preventative interventions, might protect the elderly in long-term care facilities.

The evidence contained in the Cochrane review was not great and had high risk of bias. Evidence based medicine has limitations and sometimes the BEST evidence is not great. Despite the limited data it is still recommended healthcare workers get a flu shot.

Get a flu shot I’m Bat Doc…

This podcast is going to focus on a treatment option after you have been diagnosed with the flu rather than preventing it in the first place. Neura-mini-dase inhibitors are influenza antiviral drugs often used to treat patients with the flu. Many governments stockpiled these drugs with the H5N1 scare in 2005 and increased their supplies after the 2009 H1N1 pandemic.

There were concerns these drugs were not as effective as promoted by their pharmaceutical companies. Much of this skepticism came from all the data not being available to analyze.

Clinical Question: Do neuraminidase inhibitors benefit patients’ with influenza?

Reference: Jefferson et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children (Review).  Cochrane Database Syst Rev. 2014 Apr

* Population: This review included 20 Oseltamivir (Tamiflu) trials with 9,623 participants and 26 Zanamivir (Relenza) trials with 14,628 participants. The participants were healthy people of all ages. Previously healthy includes people with chronic illness (such as asthma, diabetes or hypertension),

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Date: November 24th, 2014

Guest Skeptics: Dr. Tony Seupaul and Dr. Spencer Wright. Tony is the Chairman of the Department of Emergency Medicine, University of Arkansas.

Spencer is a PGY-3 Resident in the Emergency Medicine program at the University of Arkansas.

Five Points about American Thanksgiving:

* Lots of Travel

* Lots of Football

* Lots of Food

* Lots of Shopping

* Lots of Family

Case: A 36-year-old previously healthy white male is attending his families thanksgiving supper. He develops waves of right flank pain associated with vomiting. One of the relatives suggests it might be food poisoning. This does not go over well with the matriarch of the family. A second relative suggest he has probably been drinking too much which leads to another argument among some of the family members. Another relative who is a nurse suggests it could be renal colic and suggests he goes to the emergency department for assessment.

He arrives at the emergency department doing the hippy hippy renal colic shake. He describes the pain as sharp/stabbing and that has progressively become worse since onset. He says that over the last couple of hours he has felt that it is radiating down towards his groin. The pain has been associated with nausea and vomiting. He denies seeing any blood in his urine and has not experienced any pain with urination. There has been no diarrhea. H”e denies having a fever or a history of renal colic. The ibuprofen he took last night provided some temporary pain relief.

Background: We have covered renal colic a number of times on the Skeptics’ Guide to Emergency Medicine.. This included a randomized clinical trial done in France looking at the use of tansulosin for the expulsion of distal ureteral stones. (SGEM#4: Getting Unstoned). This small study of only 129 patients did not show superiority of tansulosin over placebo.

SGEM#32: Stone Me was a Cochrane Systematic Review looking at fluids and diuretics for rental colic. It was done by me evidence based medicine mentor Dr. Andrew Worster. The genius that started BEEM and taught me the EBM answer could always be…“it all depends”. His SR had only two small studies which met inclusion criteria. The conclusion was no reliable evidence was available to support the use of fluids or diuretics to treat renal colic.

The last time we reviewed renal colic was another Cochrane Systematic Review from Zue et al. The Bottom Line was tamsulosin was useless in most emergency department patients with ureteral colic unless their stone size exceeds at least 4mm. (SGEM#71: Like a Rolling Kidney Stone).

This time we are not going to be talking about renal colic treatment but rather diagnostic strategies.

Clinical Question: In ED patients with suspected renal colic, is ultrasound as effective as CT as a diagnostic tool?

Reference: Smith-Bindman et al.Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. NEJM 2014

* Population: 2,759 patients 18-76 years of age in emergency department setting from 15 geographically diverse academic emergency departments.

* 
Intervention: Ultrasonography

* Comparison: Computed Tomography

* Outcome:

* Primary Outcome(s): 30-day incidence of high-risk diagnosis with complications related to missed or delayed diagnosis a...

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Date: November 19th, 2014

Guest Skeptics: Dr. Amy Panzenbeck and Dr. Kara Otterness. Emergency Medicine residents from the NYU-Bellevue program.

Kara is a senior EM. Her academic interests include ultrasound, simulation, and resident education. When she is not working, her other interests include exploring new places, fine dining, live music, and outdoor adventures.

Amy is a PGY4 emergency medicine resident at NYU-Belluevue. She is a native New Yorker who spent 4 years in Boston for medical school, but returned just beofre becoming a Sox fan. Amy like running, biking, and just started learning to brew her own beer.

Case: 55 year old man with a history of chronic obstructive pulmonary disease, asthma and congestive heart failure calls 911 complaining of shortness of breath. Emergency Medical Services arrive to find a patient very short of breath, diaphoretic and speaking only one-two word sentences. His respiratory rate is 40, heart rate is 110, O2 saturation 88% and afebrile. He is clearly working hard to breath. The paramedics decide to use non-invasive positive pressure ventilation on-route to support this man’s respiratory distress.

Background: Acute dyspnea is a common emergency department complaint, in 2003 this chief complaint comprised about 3.5% of more than 115 million emergency department visits nationwide.

A subset of these patients will present in respiratory distress, which is associated with increased morbidity and mortality. Often it can be hard to determine the exact etiology of the shortness of breath in a timely fashion, and therapeutic interventions need to begin before the exact diagnosis is known.

Luckily the most common culprits of respiratory distress share a common treatment modality, and that treatment is non-invasive positive pressure ventilation.

Studies have shown that acute cardiogenic pulmonary edema, chronic obstructive pulmonary disease and asthma exacerbations all benefit from non-invasive positive pressure ventilation.

Cochrane did a SR which included 32 studies (n=2,916) looking at non-invasive positive pressure ventilation for cardiogenic pulmonary edema. Compared to standard medical care non-invasive positive pressure ventilation significantly reduced hospital mortality (RR 0.66, 95% CI 0.48-0.89). This was a study done by Vital et al in 2013.

There was an older Cochrane SR from 2004 by Ram et al. They looked at non-invasive positive pressure ventilation for admitted patients with acute chronic obstructive pulmonary disease exacerbations. There 14 studies in the systematic review (n=758). It too showed a decrease in mortality (RR 0.52, 95% CI 0.35 to 0.76)

Non-invasive positive pressure ventilation has also shown to benefit asthma exacerbations. The Cochrane SR by Lim et al identified six trials for inclusion. Their primary outcome was endotracheal intubation. This is because it is very rare for asthmatics to die and there were no deaths in any of these studies.

There was only two studies in this SR looking at their primary outcome of intubations. These were small studies with a total of 86 patients and only 2 intubations. With such small numbers they could not find a difference between the non-invasive positive pressure ventilation group and standard care.

However, with limited data they were able to show reduced hospitalizations, increased the number of patients discharged from the emergency department and improvement in some surrogate non-patient oriented outcomes like reparatory rate and lung function measurements.

* D.O.P.E. Mnemonic: Check out EMCrit Podcast

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Date:  September 29th, 2014

Guest Skeptic: Dr. Anthony Crocco. Associate Professor, McMaster University, Medical Director and Division Head McMaster Children’s Hospital Emergency Department. RANThony#1: Fever Fear.

Case: 2-year-old presents with flu-like symptoms and a fever.

Questions:

*

Should parent’s combine/alternate acetaminophen and ibuprofen?

*

Will treating the fever make her sicker, longer?

*

Will treating with antipyretics prevent a febrile seizure?

Background: Parent’s are often very concerned about fever in their children. They can develop a real “fever fear” and come into the emergency department for evaluation and reassurance. However, we need to help educate them that fever alone is not dangerous.

Here is what the American Academy of Pediatrics Guides say about fever “…fever, in and of itself, is not known to endanger a generally healthy child.  In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.”

Questions #1: Should parent’s combine/alternate acetaminophen and ibuprofen?

Reference: Wong T, Stang AS et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database of Systematic Reviews 2013.

* Population: Randomized controlled trials examining children (<18yrs) with new fever

* Intervention: Combined or alternating therapy of paracetamol and ibuprofen

* Comparison: Isolated therapy of either paracetamol or ibuprofen. Alternating therapy as a comparison to combined therapy

* Outcome: 

* Primary: Child discomfort; number of doses of medications given; absences from daycare/school; proportion of febrile children at 1/4/6 hrs post treatment.

* Secondary: Adverse events

Authors’ Conclusions: “There is some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive. There is insufficient evidence to know which of combined or alternating therapy might be more beneficial.”

Quality Checklist for Systematic Review: 

* The clinical question is sensible and answerable. Unsure

* The search for studies was detailed and exhaustive. Yes

* The primary studies were of high methodological quality. Yes

* The assessments of studies were reproducible. Yes

* The outcomes were clinically relevant. Unsure

* There was low statistical heterogeneity for the primary outcome. Yes

* The treatment effect was large enough and precise enough to be clinically significant. Yes

Key Results: Temperature was lower after combined treatment.

* 1 hour (MD -0.27, 95%CI -0.45 to -0.08)

* 4 hours (MD -0.70, 95%CI -1.05 to -0.35)

* 6 hours (MD -1.30, 95%CI -2.01 to -0.59)

Alternating therapy improved comfort compared to single therapy (Analysis 2.1) as well as decreased absent days from daycare by -0.88 (95%CI -1.02 to -0.74).

This is a reasonably well-performed systematic review and meta-analysis. Cochrane usually does a good job. There were no restrictions on language/publication type and...

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Date: October 28th, 2014

Guest Skeptics: Dr. Matt Dawson. Director of Point of Care Ultrasound at the University of Kentucky. Co-creator of Ultrasound Podcast, Introduction to Bedside Ultrasound Volumes 1 and 2 digital textbooks, One Minute Ultrasound smartphone app, Sonocloud, and other random ventures. He has received numerous awards teaching awards.

Dr. Mike Mallin. Director of Emergency Ultrasound and the Emergency Ultrasound Fellowship at the University of Utah. He is particularly interested in echocardiography and has sat for and passed the Echo Boards. He is published in multiple journals that can be found in your trash can.

Case: 66-year-old man develops sudden onset back/flank pain. He has a history of hypertension and smokes cigarettes. You are concerned about a potential acute abdominal aneurysm. A CT abdomen has been ordered and is pending.

Questions: How reliable is a bedside emergency department ultrasound for detecting acute abdominal aneurysm?

Background: The prevalence of triple A is 1.3-15% in emergency department adults and increases with age. It’s greatest in males over 65 with a history of smoking and hypertension, in fact the Cochrane Review actually recommends screening ultrasounds in these patients.

The patients population seen the in emergency department and critical care, the symptomatic one, the prevalence is as high as 23%.

These are patients that are the absolute definition of “can’t miss” The mortality with rupture approximately 90 percent.

There is no combination of history or physical findings that can reliably exclude acute abdominal aneurysm.

Reference: Rubano et al. Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm. Acad Emerg Med 2013

This paper is part of evidence based diagnostic series in Academic Emergency Medicine. The decision editor for this is the same guy who wrote the book on Evidence Based Emergency Care, Dr. Chris Carpenter.

* Population: Adult patients with suspected AAA (7 studies, n=655 patients

* Intervention: ED US by emergency physicians

* Comparison: Confirmation gold standards (Table 1 – radiologist interpretation of ED US, radiologist US, CT abdomen, angiography and laparotomy results)

* Outcome: Diagnostic performance of ED US by emergency physicians to detect triple A

Authors’ Conclusions: “Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients.”

Quality Checklist for Systematic Review:

* The diagnostic question is clinically relevant with an established criterion standard. Yes
 Comment: See Table 1: various gold standards including radiologist interpretation of ED US, radiologist US, CT abdomen,

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Date: October 8th, 2014

Guest Skeptic: Meghan Groth (@EMPharmGirl). Meghan is the emergency medicine pharmacy specialist at Fletcher Allen Health Care in Burlington, Vermont and an adjunct professor of pharmacy at the Albany College of Pharmacy and Health Sciences.

Case:  A 25 year old male presents to your emergency department as a trauma alert after an alleged assault. EMS reports that the patient has been minimally responsive during transport, and witnesses at the scene claimed the patient experienced blunt force trauma to the head after being beaten by another man. During the primary survey, you observe that the patient is not protecting his airway with a GCS of 6. You prepare for a rapid sequence intubation prior to the patient getting a CT scan.

His vital signs are HR 98 bpm, BP of 110/75 mmHg, RR 12/min, and SpO2 87% on a non-rebreather. You ask your ED pharmacist to prepare ketamine 2 mg/kg IV and succinylcholine 1.5 mg/kg for intubation. Additionally, you plan to use intermittent fentanyl boluses as needed after intubation to keep the patient comfortable and facilitate further evaluation, in this case a CT scan of his head.

Questions: Does ketamine raise intracranial pressure and adversely affect cerebral perfusion pressures, neurologic outcomes, or mortality compared with other intravenous induction agents commonly used to intubate adult patients in the emergency department?

Background: Ketamine is an NMDA receptor antagonist that exerts sedative, amnestic, and analgesic effects as a dissociative anesthetic. It can be used as an induction agent for rapid sequence intubation in the emergency department, and has relatively stable hemodynamic effects, especially when compared with other agents such as midazolam, propofol, or the ultra-short acting barbiturates. Despite this, the use of ketamine for RSI among ED physicians is low.

Emergency department physicians have been reluctant to use Ketamine. We have been warned not to use it in certain situations. One concern is that it could raise intracranial pressure.

Ketamine’s bad reputation comes from several small case-control series from approximately 30-40 years ago that suggested that ketamine increases ICP through sympathetic stimulation. These case-control series evaluated patients with intracranial pathology including space-occupying lesions or obstructive hydrocephalus, and were not necessarily representative of the majority of emergency department patients.

Up until just recently, etomidate may have been regarded by emergency physicians to be the induction agent of choice in RSI. However, it too now has a bad reputation. There are concerns about adrenal suppression (in the setting of sepsis) and acute lung injury (in the setting of trauma).  See SGEM#44: Pause – Etomidate and Rapid Sequence Intubation for more information.

Reference: The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic Review. Ann Emerg Med. 2014

* Population: 10 studies with 953 patients at least 16 years of age either intubated prior to or at the point of data collection.

* Exclusions: Studies were excluded if they evaluated the effects of ketamine on non-intubated patients, were written in languages other than English, or if they lacked a comparison group

* Intervention: Ketamine (either by bolus or infusion)

* Comparison: Any other sedative drug that might be used for RSI in the ED (comparisons included sufentanil, remifentanil, etomidate, and fentanyl; in case control studies the cointerventions included propofol, benzodiazepines,

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Date: October 29th, 2014

Guest Skeptic: Dr. Jeremy Faust. Emergency Medicine Resident, Mt. Sinai Hospital, New York City. Co-Creator of FOAM Cast with Dr. Lauren Westfer.

This is a Skeptics’ Guide to Emergency Medicine Extra (SGEM-Xtra). An extra blog/podcast created in addition to the weekly content.

Normally we do a structured critical review of a recent publication. This is to cut the knowledge translation window down from over ten years to less than one year. However, a SGEM-Xtra will occur when a topic comes up or people come together and there seems to be a need to produce some extra SGEM content.

This first SGEM-Xtra is being recored at ACEP 2014 in Chicago. It has been a fantastic time to meet #FOAMed friends from around the world and make some new friends.

This has been my favorite ACEP ever. That is because it has been a wonderful father-son trip. My son Ethan took his Grade Ten Science Fair project and submitted it for the meeting.

Ethan created, designed, built and tested a new paediatric spine board (Ped-E-Board) to quickly and accurately assess the weight of critically ill or injured children.

Ethan is apparently one of the youngest person to every be invited to present at the conference according to ACEP Now. I am one very, very proud dad.

Last year Jeremy and I did a podcast at ACEP in Seattle. It was called the Five Stages of Evidence Based Medicine Grief. We discussed the five stages of grief as described by Kubler-Ross. People do not experience these in order, there may be other stages and not all stages need to be experienced. We discussed the five stages of EBM grief using a number of medical studies as examples.

The Five Stages of Grief:

* Denial

* Anger

* Bargaining

* Depression

* Acceptance

This fall Jeremy contacted me and suggested we do another special episode of the Skeptics’ Guide to Emergency Medicine when we are together in Chicago attending #ACEP14. I said great, what’s the topic?

Jeremy wanted to podcast a myth busting talk he had created called: Everything you know is wrong. It was part of a myth busting competition in New York City.

The myth he chose was “the peer review process as we know it is GOOD for science and medicine.” This SGEM-Xtra is a recording of us discussing his presentation.

Bottom Line: Be skeptical, even of the peer-reviewed literature.

References:

* Dr. Jackson  “It takes 50 years to get a wrong idea out of medicine, and 100 years a right one into medicine”.

* Weird Al Yankovic – Everything You Know Is Wrong

* Bohannon J. Who’s Afraid of Peer Review. Science Oct 2013

* Baxt WG et al. Who Reviews the Reviewers? Feasibility of Using a Fictitious Manuscript to Evaluate Peer Reviewer Performance. Ann Emerg Med 1998

* Callaham ML et al. Effect of Written Feedback by Editors on Quality of Reviews Two Randomized Trials. JAMA 2002

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Date:  October 22nd, 2014 

Reference: Goal-Directed Resuscitation for Patients with Early Septic Shock. The ARISE Trial. NEJM Oct 2014

Guest Skeptic: Dr. Suneel Upadhye. Associate Clinical Professor of Emergency Medicine, McMaster University.  Associate Member Department of Clinical Epidemiology and Biostatistics. Chair Canadian Association of Emergency Physicians Standards Committee. Sepsis Researcher.

Case: 62-year-old man sent from a nursing home with a three day history of a productive cough, intermittent fevers and today is a bit confused.  The transfer notes include a history of congestive heart failure, COPD, gout, hypertension, type-2 diabetes, and mild dementia.  His vital signs are as follows: Temp 39.1C, heart rate 103, blood pressure 115/100, respiratory rate 26, Oxygen saturation Sat 92% and a normal blood sugar.

Questions: Does an ED patient with septic shock need aggressive EGDT or “usual” resuscitation?

Background: Suneel’s Five Key Points of Sepsis Care

* Recognize sepsis early

* Broad spectrum antibiotics

* Fluid resuscitation

* Lactate levels

* Transfer to appropriate care

Reference: Goal-Directed Resuscitation for Patients with Early Septic Shock. The ARISE Trial. NEJM Oct 2014

* Population: Adults >18yo presenting to emergency department within 6hrs with suspected/confirmed infection, 2+ SIRS criteria, and evidence of refractory hypotension (sBP<90 or MAP<65 after IVF >1000ml within 1st hour) or hypoperfusion (lactate >4).

* Exclusions: Age <18-years-old, contraindications to central venous catheter/blood products, imminent/inevitable death, underlying disease with <90 day life expectancy, inpt transfer from another facility, confirmed/suspected pregnancy, unable to randomize or start EGDT within 6-hours of ED arrival.

* Intervention: Full EGDT provided by a trained study team using a standardized EGDT delivery protocol

* Control: “Usual” care as per physician discretion. Use of SCVO2 NOT allowed. All patients mandated for IV antibiotics prior to randomization.

* Outcome:

* Primary Outcome: All-cause mortality at 90 days.

* Secondary/Tertiary Outcomes: 90 day survival time, ICU mortality, 28d mortality, in-hospital 60d mortality, cause-specific 90d mortality, length of stay in ED/ICU/hospital, use of critical interventions (mech ventilation, vasopressor support, renal dialysis), discharge destination of survivors, adverse events. A priori subgroup analyses for demographics, APACHE scores, mech ventilation, refractory hypotension, lactate level, and IV fluid resuscitation volume (<20cc/kg vs >20cc/kg).

Authors’ Conclusions: “In critically ill patients presenting to the emergency department with early septic shock, EGDT did no reduce all-cause mortality at 90 days.”

Quality Check List for Randomized Control Trials:

* The study population included or focused on those in the Emergency Department. Yes All patients were recruited from the ED Yes. All patients were recruited from the emergency department.

* The patients were adequately randomized. Yes

* The randomization process was concealed. Yes

* The patients were analyzed in the groups to which they were randomized. Yes

* The study patients were recruited consecutively (i.e. no selection bias). Yes

* The patients in both groups were similar with respect to prognostic factors. Yes

* All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No