Previous work in severe sepsis/septic shock patients has shown that a decrease in lactate concentration by at least 10% during emergency department resuscitation predicts survival. Since this is a potential alternative resuscitation goal to a central venous oxygen saturation (ScvO2) of 70% (as per surviving sepsis campaign guidelines), lactate clearance was compared with ScvO2 in a randomised non-inferiority trial of 300 patients.
All patients were managed in the ED and received fluids, antibiotics, and vasopressors as needed. Then lactate clearance or ScvO2 were measured, and if the respective goals of 10% or 70% were not met, packed cells or dobutamine were given depending on haematocrit. Lactate clearance was the percentage decrease in lactate between two venous specimens taken two hours apart.
Interestingly only 29 patients received either packed cells or dobutamine. Each group was similar in terms of time to antibiotic therapy and amount of fluid given. Patients in the group resuscitated to a lactate clearance of 10% or higher had 6% lower in-hospital mortality than those resuscitated to an ScvO2 of at least 70% (95% CI for this difference, –3% to 15%) exceeding the –10% predefined noninferiority threshold.
The authors conclude ‘these data support the substitution of lactate measurements in peripheral venous blood as a safe and efficacious alternative to a computerized spectrophotometric catheter in the resuscitation of sepsis.’
Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
JAMA. 2010 Feb 24;303(8):739-46
Category Archives: Resus
Life-saving medicine
Noradrenaline vs Dopamine in Shock
Another nail in dopamine’s coffin? In a blinded randomised controlled trial in shocked patients1, there was no difference in mortality when dopamine was compared with noradrenaline as the initial vasopressor. However the dopamine group had a significantly higher incidence of dysrythmia. In addition, mortality was higher in the predefined subgroup of 280 patients with cardiogenic shock. The results of this European study of 1679 patients are very similar to those of a similar but open-label American trial in 252 patients published recently2.
1. Comparison of Dopamine and Norepinephrine in the Treatment of Shock
NEJM 2010;362(9):779-89
2. Efficacy and Safety of Dopamine versus Norepinephrine in the Management of Septic Shock
Shock. 2009 Oct 21. [Epub ahead of print]
Cricoid pressure squashes kids' airways
A bronchoscopic study of anaesthetised infants and children receiving cricoid pressure revealed the procedure to distort the airway or occlude it by more than 50% with as little as 5N of force in under 1s and between 15 and 25N in teenagers. Therefore forces well below the recommended value of 30 N will cause significant compression/distortion of the airway in a child
Effect of cricoid force on airway calibre in children: a bronchoscopic assessment
Br J Anaesth. 2010 Jan;104(1):71-4
A novel jaw thrust device
A novel jaw thrust device (JTD) was tested against oropharyngeal and nasopharyngeal airways in anaesthetised patients. The JTD enabled effective ventilation with less airway resistance than the traditional airways, and so provided greater tidal volumes during pressure controlled ventilation. It fits into the mouth, keeping the mouth open and the jaw thrusted forward, and has a standard sized connector for attachment to ventilation devices.
Optimising the unprotected airway with a prototype Jaw-Thrust-Device – a prospective randomised cross-over study
Anaesthesia. 2009 Nov;64(11):1236-40
Take bloods before giving Lipid Rescue
Intralipid therapy is recommended for local anaesthetic toxicity and in some overdoses. After large doses of Intralipid, the results of blood tests may be difficult to analyse, delayed, or spuriously abnormal. If possible, all blood tests should be taken before the administration of Intralipid. While laboratories will readily identify significant lipaemia, communication about the presence of Intralipid is important. In one case, the inability to obtain a haemoglobin result led to delay in the identification of haemorrhage which was the cause of deterioration initially thought to be local anaesthetic toxicity.
Possible side effects of Intralipid rescue therapy
Anaesthesia 2010;65(2):210-11
Best position for RIJV cannulation in kids
In a study of anaesthetised infants and children, the right internal jugular vein as assessed by ultrasonography was measured with the head in the neutral position, and then at 40 degrees and 80 degrees of rotation to the contralateral side. The 40 degree position resulted in an increase in IJV diameter but with less overlap with the carotid artery than the 80 degree position. The authors conclude that rotating the head 40 degrees to the left results in the best balance of increased IJV diameter versus overlap with the carotid.
Effects of head rotation on the right internal jugular vein in infants and young children
Anaesthesia Volume 65, Issue 3, Pages 272-276
Supraclavicular approach to subclavian vein
A series of subclavian vein catheterisations is described in patients using the supraclavicular approach, with a high success rate and few complications. 290 of the 370 patients were mechanically ventilated at the time of the procedure
How they did it:
- The point of needle insertion was identified 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculosternocleidomastoid angle)
- The direction of the needle was indicated by the line that bisects the claviculosternocleidomastoid angle with elevation 5–15 degrees above the coronal plane.
- The needle was advanced slowly with a constant negative pressure in the syringe.
- The vein was usually punctured between the clavicle and the attachment of the anterior scalene muscle to the first rib.
- The subclavian artery is situated posterior and slightly superior to the vein; if palpable, the pulse of the artery could be the important landmark
- The depth of catheter insertion was 14 cm for right side and 18 cm for left side catheterization.
Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts
Anesthesiology. 2009 Aug;111(2):334-9
EMRAP.TV has a video on supraclavicular central line insertion here
Pre-hospital thoracotomy and aortic clamping in blunt trauma
This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4
Some causes of a raised lactate
A high serum lactate does not necessarily mean a bad prognosis: it all depends on the cause.
I made this diagram as a mnemonic for the causes of high lactates:
Additional information added 1st June 2011: One cause of an elevated lactate may be artefactual, secondary to interference with the assay (used on ABG machines) by ethylene glycol. The assay may also be subject to interference from certain drugs at toxic levels such as isoniazid, acetaminophen and thiocyanate. This information is from the Renal Fellow Network.
Paediatric ketamine sedation: adverse events
Records of 4252 patients aged 0-19 who received ketamine were reviewed for documented adverse events. Patients were all American Society of Anesthesiology Class I or II. 102 (2.4%) had an ‘adverse event’, defined as the occurrence of hypoxia by oxygen saturation lower than 93% on room air or clinical cyanosis, documentation of laryngospasm, airway obstruction, or apnea diagnosed clinically or by capnography, stridor, respiratory distress, or hypoventilation or hypercarbia as assessed by capnography. Cases with adverse events were compared with controls who had received ketamine without adverse events, but were not otherwise matched.
Of the adverse events, laryngospasm was documented to have occurred in 29/4252 cases (0.7%), hypoxia in 81/4252 (1.9%), and positive pressure ventilation was required in 33/4252 (0.8%). Intubation was required in one patient (0.023%). Compared with controls, patients with adverse events were more likely to have received IM, as opposed to IV, ketamine, although children who received IM ketamine were more likely to be younger than those who received IV ketamine (4.1 vs 7.9 years).
The retrospective design and other methodological limitations make it harder to draw conclusions other than what we know from existing literature, to which this large series adds: ketamine is given to a lot of kids with few adverse effects; larygnospasm is a real but infrequent occurrence that usually responds to simple manouevres; and intubation is extremely rarely required, but nevertheless may be necessary and therefore those physicians using ketamine should have advanced airway skills.
Serious Adverse Events During Procedural Sedation With Ketamine
Pediatr Emerg Care. 2009 May;25(5):325-8