Transjugular intrahepatic portosystemic shunt (TIPS) is often used as a rescue therapy in cirrhotic patients with variceal haemorrhage after vasoactive drug therapy and endoscopic ligation have failed. A randomised study compared this standard management with earlier TIPS within 72 hours after randomisation (and randomisation occurred within 24 hours of admission). The early use of TIPS was associated with significant reductions in treatment failure and in mortality.
Not sure what TIPS is? This video I found on YouTube explains it nicely..
[youtube]http://www.youtube.com/watch?v=pGA6KUgq7AI&feature=related[/youtube]
Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding
NEJM 2010;362:2370-2379
Poor pre-hospital intubation success
A Scottish study of 628 pre-hospital intubation attempts in cardiac arrest patients records the rate of successful intubations, oesophageal intubations, and endobronchial intubations. Prehospital tracheal intubation was associated with decreased rates of survival to admission. This study has the limitations of a retrospective series but indirectly provides some further muscle to the supraglottic airway lobby.
Field intubation of cardiac arrest patients: a dying art?
Emerg Med J. 2010 Apr;27(4):321-3
Pre-sedation fasting unnecessary
A thorough review of the emergency medicine sedation literature showed there is only one reported case of pulmonary aspiration during emergency procedural sedation, among 4657 adult cases and 17 672 paediatric cases reviewed. The authors of the review remind us that the often (inappropriately in the ED) quoted American Society of Anesthesiology guidelines for fasting prior to general anaesthesia are based on questionable evidence, and there is high-level evidence that demonstrates no link between pulmonary aspiration and non-fasted patients. There is no reason to recommend routine fasting prior to procedural sedation in the majority of patients in the Emergency Department.
An accompanying editorial points out that like other systematic reviews, the methodological flaws of the studies examined are likely to have limited the conclusions of this review.
The review authors and the editorialist agree that despite the lack of evidence linking fasting status to aspiration, selected patients believed to be significantly more prone to aspiration may benefit from risk:benefit assessment prior to sedation.
Something I learned from reading the review: ‘ it is now recognised that asymptomatic aspiration of gastric contents occurs physiologically during normal sleep‘. How about that.
Pre-procedural fasting in emergency sedation
Emerg Med J. 2010 Apr;27(4):254-61
What fluid in rhabdomyolysis?
A ‘BestBET‘ from the Emergency Medicine Journal examined the evidence for the use of sodium bicarbonate and/or mannitol in the management of rhabdomyolysis.
The clinical bottom line: there is no quality published evidence that alkaline diuresis is a superior treatment to normal saline alone.
Rhabdomyolysis and the use of sodium bicarbonate and/or mannitol
Emerg Med J. 2010 Apr;27(4):305-8
Full Text at the BestBets site
Oxygen in AMI – no benefit, possible harm
A Cochrane review examined the evidence from randomised controlled trials to establish whether routine use of inhaled oxygen in acute myocardial infarction (AMI) improves patient-centred outcomes, the primary outcomes being death, pain and complications.
Three trials involving 387 patients were included and 14 deaths occurred. The pooled relative risk (RR) of death was 2.88 (95% CI 0.88 to 9.39) in an intention-to-treat analysis and 3.03 (95% CI 0.93 to 9.83) in patients with confirmed AMI. While suggestive of harm, the small number of deaths recorded meant that this could be a chance occurrence. Pain was measured by analgesic use. The pooled RR for the use of analgesics was 0.97 (95% CI 0.78 to 1.20).
There is therefore no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute AMI. A definitive randomised controlled trial is required.
Oxygen therapy for acute myocardial infarction
Cochrane Review
B lines be gone!
Vicki Noble’s Emergency Ultrasound team describe the resolution of Songraphic B lines on the lung ultrasound of a patient with end stage renal disease who presented with dyspnoea due to pumonary oedema which was treated with CPAP.
B-lines are hyperechoic vertical lines that originate at and slide with the pleura and extend radially to the edge of the screen without fading. Isolated B-lines may be seen in normal lungs, but diffuse B-lines in multiple zones indicate interstitial thickening, most commonly seen in congestive heart failure (CHF).
This case is interesting because it describes real-time resolution of B-lines during therapy in the ED demonstrating that in CHF, B-lines reflect acute rather than chronic changes within lung parenchyma.
Real-time resolution of sonographic B-lines in a patient with pulmonary edema on continuous positive airway pressure
Am J Emerg Med. 2010 May;28(4):541.e5-8
Hydrocarbon lakes on Titan
It’s a stretch – but Saturn’s largest moon Titan could support methane-based life forms. It is the only other place in the Solar System than Earth that is known to have liquid on its surface. Not liquid water though – which would freeze at Titan’s temperature of minus 283 degrees Celsius, but liquid hydrocarbons.
An interesting finding shows hydrogen molecules flowing down through Titan’s atmosphere and disappearing at the surface. Another is that maps of hydrocarbons on the surface show a lack of acetylene, (used on Earth as welding gas). One explanation is that methane-based life forms are eating it. Sensibly, Mark Allen, principal investigator with the NASA Astrobiology Institute Titan team, said: “Scientific conservatism suggests that a biological explanation should be the last choice after all non-biological explanations are addressed.”
Nevertheless, the thought of cool science like this keeps me warm at night. Nature keeps coming up with stuff far more exotic and wondrous than our own ancient magical myths ever imagined.
More information at Spaceinfo.com.au
Stroke thrombolysis benefit decays with time
Pooled results of several trials comparing recombinant tissue plasminogen activator with placebo in ischaemic stroke quantify the profile of benefit and harm for alteplase in broadly selected patients. Generally, alteplase appears to improve the outcome of one in three patients treated between 1 and 3 h from onset and of one in six patients treated in the 3–4·5 h window, but confers no net benefit beyond that time. Benefit may decrease exponentially (according to an accompanying editorial), so if you are a believer then get in there early.
Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials
Lancet. 2010 May 15;375(9727):1695-703
Misoprostol for PPH
Misoprostol is a prostaglandin analogue with uterotonic activity. It was compared with placebo in its sublingual form in a randomised trial in 1422 women with postpartum haemorrhage and uterine atony. It was given with other uterotonic agents (mostly oxytocin 10IU im or slow iv). The primary outcome was blood loss of 500 mL or more within 60 min after randomisation, and this was similar in both groups.
Misoprostol as an adjunct to standard uterotonics for treatment of post-partum haemorrhage: a multicentre, double-blind randomised trial
Lancet. 2010 May 22;375(9728):1808-13
Lung Ultrasound Articles
Here are some sites that explain lung sonography as applied to critical care patients:
Clinical review: Bedside lung ultrasound in critical care practice – Critical Care Full Text
Evaluation of ultrasound lung comets by hand-held echocardiography – Cardiovascular Ultrasound Full Text
ICU Sonography Site – Lung Ultrasound Tutorial