In a randomised, multicentre trial of 1316 infants born between 24 weeks 0 days and 27 weeks 6 days of gestation, infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks.
Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to be alive and free from the need for mechanical ventilation by day 7 (P=0.01). However the rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05).
The infants randomised to CPAP could receive limited invasive ventilation if necessary; 83.1% of the infants in the CPAP group were intubated. They did not include infants who were born at a gestational age of less than 24 weeks, since the results of a pilot trial showed that 100% of such infants required intubation in the delivery room.
This study had a 2-by-2 factorial design in which infants were also randomly assigned to one of two target ranges of oxygen saturation.
Early CPAP versus Surfactant in Extremely Preterm Infants
N Engl J Med. 2010 May 16. [Epub ahead of print]
Category Archives: All Updates
Carotid Artery Stenting versus Endarterectomy
The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) compared the outcomes of carotid-artery stenting with those of carotid endarterectomy among over 2500 patients with symptomatic or asymptomatic extracranial carotid stenosis.
The authors offer the following conclusions:
- Stroke was more likely after carotid artery stenting.
- Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
- Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy; older patients had fewer events after carotid endarterectomy.
- The low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and may also reflect advances in medical therapy.
Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis
NEJM May 26 2010 Published Online
Guidelines for Clostridium Difficile
Guidelines for preventing, detecting, and treating Clostridium Difficile infection from the Infectious Diseases Society of America have been published.
Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
Infect Control Hosp Epidemiol 2010;31:431–455 Full Text
Bloodtest Not Pertinent (BNP)
Despite a lack of evidence that it’s useful, many emergency departments have introduced BNP testing. Some smart Australians decided to properly evaluate its benefit the best way possible – with a randomised controlled trial on 612 patients with acute severe dyspnoea. Guess what? Clinician knowledge of BNP values in patients who presented with shortness of breath to the emergency department did not reduce the probability of hospital admission or alter management or length of hospital stay. The study findings do not support indiscriminate BNP testing in all dyspnoea patients, but do not rule out a possible role in patients with milder dyspnoea.
B-type natriuretic peptide testing, clinical outcomes, and health services use in emergency department patients with dyspnea: a randomized trial
Ann Intern Med. 2009 Mar 17;150(6):365-71
PCI and therapeutic hypothermia
Percutaneous coronary intervention did not increase the risk of dysrhythmia, infection, coagulopathy, or hypotension associated with therapeutic hypothermia after cardiac arrest. Intensivists and cardiologists should perhaps agree that this adds to existing evidence that the two therapies are not mutually exclusive.
Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest
Resuscitation. 2010 Apr;81(4):398-403
The myth of ketamine and head injury
A literature review addresses the myth that ketamine is contraindicated in head injured patients. They summarise articles from the 1970’s which identified an association between ketamine and increased ICP in patients with abnormal cerebrospinal fluid pathways (such as those caused by aqueductal stenosis, obstructive hydrocephalus and other mass effects). In more recent studies no statistically significant increase in ICP was observed following the administration of ketamine in patients with head injury; some of the studies showed a net increase in CPP following ketamine administration. They list ketamine’s stable haemodynamic profile and potential neuroprotective effects as further rationale for its use.
The authors boldly summarise:
‘Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head-injured patients for intubation.’
Myth: ketamine should not be used as an induction agent for intubation in patients with head injury
CJEM. 2010 Mar;12(2):154-7
Rapid discharge in AF
The Ottawa Aggressive Protocol is used to treat recent onset (< 48 hours) atrial fibrillation or flutter with procainamide and/or cardioversion to allow discharge from the emergency department.
A cohort of 660 patient visits is described in a paper in the Canadian Journal of Emergency Medicine, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.
This proactive approach by emergency physicians seems excellent for patients who in some centres probably still get admitted for this presentation. I’m not sure why they continue to use a drug with a conversion percentage in the 50’s, which the authors have demonstrated before. Many of us routinely use flecainide for recent onset AF in patients likely to have structurally normal hearts, as it has been shown to be superior to procainamide in AF.
Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
Canadian Journal of Emergency Medicine 12.3 (May 2010): p181(11)
Vital signs of severely injured children
Systolic blood pressures of severely injured children are very often hypertensive compared with APLS ‘norms’. A lower pulse rate is associated with more severe brain injury
Comparing the systolic blood pressure (SBP) and pulse rate (PR) in injured children with and without traumatic brain injury
Resuscitation. 2010 Apr;81(4):418-21
Optimum depth of neonatal chest compressions
A retrospective study of infant chest CT scans using mathematical modelling and a number of assumptions suggests that neonatal CPR according to AAP/AHA guidelines of compressing to one third anteroposterior chest wall diameter should provide a superior ejection fraction to 1/4 depth and should generate less risk for over-compression than 1/2 AP compression depth.
Evaluation of the Neonatal Resuscitation Program’s recommended chest compression depth using computerized tomography imaging
Resuscitation. 2010 May;81(5):544-8
Compare their conclusions with those of the authors of this case series of arterial-line monitored cardiac arrests in infants with a median age of one month
Hospital bypass for cardiac arrest?
A Japanese study of over 10,000 patients demonstrated improved neurological outcome in out-of-hospital cardiac arrest patients who were taken to hospitals designated as ‘critical care medical centres’, where neurologically favorable 1-month survival was greater [6.7% versus 2.8%, P < 0.001] despite a slightly longer call-hospital arrival interval [30.6 min vs 27.2, p < 0.001]. If return of spontaneous circulation was achieved pre-hospital, there was no difference in survival. It is unclear what factors, such as more interventional cardiology or therapeutic hypothermia, made the difference in the critical care centres.
Impact of transport to critical care medical centers on outcomes after
out-of-hospital cardiac arrest
Resuscitation. 2010 May;81(5):549-54