Grand Rounds Recap 7.10.19

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Great Debate: Rocuronium vs. Succinylcholine WITH DRS. Lang and Plash

Succinylcholine

  • Onset of action 45-60 seconds, which is comparable to 1.2mg/kg of rocuronium

  • Duration of action 5-10 minutes

    • This is beneficial for being able to follow the patient’s neurologic examination

    • Quick duration of action also benefits allowing patient to auto-regulate respiratory rate to help compensate for an underlying metabolic acidosis

  • If reversal anticipated, cheaper than sugammadex for reversal of rocuronium

  • Cochrane Review: succinylcholine had better intubating conditions and faster onset of action than rocuronium, although no change in success rates

  • Faster desaturation time associated with succinylcholine, but no evidence of significant adverse effects related to this

  • Reported contraindications to rocuronium:

    • Carcinomatosis

    • Neuromuscular disease

    • Burns

    • Anticonvulsants

    • Prolonged QTc

    • Increased pulmonary vascular resistance

  • NEAR Database: no difference in intubating success or adverse events between succinylcholine and rocuronium

Rocuronium

  • On the market in early 1990s

  • First comparison trial in 1992 by Huizinga et al.

    • A lot of the results from this study have now been disproven with further research

  • Dosing: majority of studies including 0.6-0.8 mg/kg; however, higher dosing may be more effective

  • Per Cochrane Review, there is no significant difference in intubating conditions when higher doses of rocuronium are used

  • Based on Taha et al. and Tang et al., there is significantly quicker desaturation times with succinylcholine compared to rocuronium

  • May improve ‘Can’t Intubate Can’t Oxygenate’ (CICO) outcomes with prolonged paralysis, although this is opinion based

  • Similar time to intubation with appropriate dosing of 1.2 mg/kg

  • Potential downsides:

    • Extended duration of paralysis - can’t follow neuro exam, higher likelihood for inappropriate sedation

    • Neuro patients - is the decision to go to the OR based more on exam or more on CT scan?, rocuronium may decrease hypoxic events based on desaturation data

MasterS Class  WITH DRs. Moellman and Ryan

  • Philosophy

    • Be aware of the “efficiency ceiling” midway through a shift

    • Think the worse and prove it wrong

    • If you think too hard about performing a test, just do it

    • Balance science vs experience

    • Document in a timely manner

    • Pertinent negatives > pertinent positives

  • Case 1

    • Young male brought in by EMS strapped down, naked, with a spit mask in place after being found running around with altered mental status

    • Chemical restraint with haloperidol and midazolam

    • Work up largely negative, including head CT

    • Dx: patient’s typical post-ictal phase includes running around naked

    • On reassessment, the patient was back to his normal mental status and had been post-ictal

    • Post-ictal psychosis is a true diagnosis, so be sure to think about it on your differential diagnosis with acute changes in mental status

  • Case 2

    • Female patient with possible pregnancy who “can’t see”

    • 38 weeks OB, hypertensive, seizing

    • Dx: eclampsia

    • Started on oxygen, seizure precautions, labetalol/hydralazine, magnesium, IVF

    • Talk with OB, neonatal resuscitation team, pharmacy

    • Know your consultants

  • Case 3

    • Male bit in finger by “black-necked spitting cobra”

    • Crofab is not an option because it is an Elapidae species

    • No antivenom available in Cincinnati, but available in Kentucky

    • AirCare dispatched to retrieve antivenom, treated successfully

    • Know your resources

  • Case 4

    • Young male woke up with “eyes hurting”

    • Conjunctival injection, cylinder hair in conjunctivae with fluorescein staining

    • Tarantula hairs come loose when it shakes its body, so he had tarantula hairs in his eyes

    • Must remove manually, inflammation treated with steroid antibiotic drops

    • Be thorough in your history taking

  • Case 5

    • Middle aged male with flank pain, diarrhea, sweating

    • Labs and CT normal

    • Ready to be discharged, but family arrived stating this was how he presented with his last heart attack

    • Dx: Inferior STEMI 2/2 RCA with in-stent stenosis

    • Ask your patients if they have had similar symptoms before

  • Case 6

    • Young male with DD presents with genital pain?

    • L testicle TTP and swelling without mass

    • Ultrasound with concern for scrotal cellulitis

    • Return visit 2 days later with Fournier’s gangrene

    • Use tools to communicate with patients who are unable

  • Case 7

    • Middle age female with “stroke”

    • Dysarthria, lethargy, glucose normal

    • In CT, develops respiratory distress

    • On reassessment, has ACE-inhibitor induced angioedema

    • In the era of protocolized medicine, be aware of the mimics

  • Case 8

    • Young male who “can’t move my legs”

    • On exam, cannot move his proximal legs

    • Found to be hypokalemic period paralysis with thyrotoxic cause

    • Use your lifelines

    • Document AMAs thoroughly

Pharmacy Update WITH DR. Paige Garber and Nicole Harger

 Oral Anticoagulant Reversal

  • Oral anticoagulation can be beneficial for VTE prophylaxis, as they do not need monitoring or bridging

    • However, they do require BID dosing which can be be challenging in noncompliant patients

  • Dabigatran

    • Poor oral bioavailability

    • Can be reversed with RRT as it is not protein bound

    • FFP and activated 4-factor PCC are nonspecific agents for reversal

    • Idarucizumab is a specific monoclonal antibody that has been approved for reversal

      • Dosing is 5g IV (two 2.5g boluses within 15 minutes of each other)

  • Oral Direct Xa Inhibitors (including rivaroxaban, apixaban, edoxaban, and betrixaban)

    • Relatively short half-lives, so important to determine last dose of these medications

    • Non-activated 4-factor PCC is non-specific

    • Andexanet alpha binds and inhibits factor Xa drugs to cease activity of anticoagulant drugs but has no specific activity to reverse anticoagulation

    • No comparative data available between PCC and andexanet alpha

    • Current recommendations support 4-factor PCC (50 units/kg) but all were published prior to andexanet alpha

    • ANNEXA-4

      • Included patients on apixaban, rivaroxaban, and enoxaparin

      • 352 patients with acute major bleed with last dose within 18 hours

      • Excluded ICH with decreased GCS or volume greater than 60cc and patients with planned surgery

      • Overall good or excellent hemostasis achieved in 82% of patients

      • Mean time to bolus was 4.8 hours

      • Thrombotic events: 18%

      • Mortality: 15%

      • Rebound effect of similar anti-factor Xa levels after infusion of drug is completed

Droperidol

  • Initially formulated in the 1950s

  • FDA black box warning in 2001 regarding QT prolongation

  • Shortage in 2012 causing the drug to go absent on the US market

  • Relaunched in 2019

  • Mechanisms of action: Butyrophenone antipsychotic

    • Dopamine blockade

    • Alpha adrenergic blockage

    • GABA agonist

  • Onset 3-10 minutes with peak effect 30 minutes

  • Duration 2-4 hours

  • Dosage:

    • FDA approved for Post operative nausea and vomiting (PONV): 0.625-1.25 mg

    • Agitation (off-label): 1.25-2.5 mg

  • Adverse effects

    • QTc prolongation

    • Tachydysrhythmia

  • Contraindicated

    • QTc > 440 males, > 450 females

    • Hypersensitivity

  • Droperidol increases QTc on average 25ms, compared to haloperidol 4.7ms and ziprasidone 21ms

  • Warning in patients with buproprion, as this lowers the seizure threshold

  • Doses greater than 1.25 mg require continuous cardiac monitoring

  • Baseline EKG needed prior to administration, although may not be possible in agitated patients

  • PONV

    • Statistically significantly better than metoclopromide

  • Headaches

    • 2015 American Headache Society guidelines: droperidol class level B

    • Many RCTs comparing to other typical agents used in headache with similar outcomes

  • Agitation

    • Median time to reach “calmness” 8-25 minutes, similar to other treatment options

Loxapine

  • Newer medication for agitation with onset within 2 minutes

  • Delivered via inhaler

  • Efficacy:

    • Decreased agitation in schizophrenia and bipolar disorder

    • Decreased time in restraints

    • Patients and staff both have high satisfaction with drug

    • Reduced time to disposition, about 3 hours less

  • Adverse effects: respiratory distress, especially in patients with underlying obstructive lung disease

    • Albuterol worsens bronchospasm

    • Limited use to one dose every 24 hours

  • Dosing: 10 mg

Clinical Decision Making WITH DR. Hill

  • Study by Pelaccia et al. in 2014 indicated 77% of differential diagnoses were generated by the physician within 5 minutes of talking with a patient

    • The range of items on the differential diagnosis was 4-8

    • Immediate hypotheses were based on intuition, while later items were more based on conscious effort

  • Recognition Primed Decision Making (Klein)

    • People use their experience to form a repertoire of patterns

    • Decision making is dependent on matching a scenario to a known pattern

  • Dual Process Decision Making (Kahneman)

    • System 1: Fast, subconscious, pattern recognition, can be high capacity, independent of working memory, low mental effort

    • System 2: Slow, conscious, low capacity, rule based, analytic and reflective

  • Types of Cognitive Bias

    • Anchoring

    • Premature Closure

    • Representativeness Restraint

    • Search Satisfying

    • Sutton’s Slip

    • Triage-Curing

    • Unpacking Principle

    • Vertical Line Failure

    • Playing the Odds

    • Omission Bias

    • Confirmation Bias

    • Overconfidence

    • Psych-Out Error

    • Diagnosis Momentum

NIHSS WITH Dr. Knight

  • Review of appropriate NIHSS calculation

  • Pointers:

    • Can do visual velds and visual extinction/neglect testing at the same time

    • Hold both arms up for them and ask patient to keep up against gravity for 10 seconds

    • When testing limb ataxia, be sure to make patient fully extend arm and be in the visual field the patient can see

    • Do not test ataxia in hemiparetic/hemiplegic limb, as does not add to points if ataxic

      • Ataxia must be out of proportion to weakness

    • Aphasia can be complex; if patient can describe a pen, but not name “pen,” they still have significant aphasia without dysarhria

    • Strokes do not cause acute stuttering

    • Gaze deviation will be deviated toward side of stroke and away from source location of seizure

    • Deficits from old strokes are included in your NIHSS

    • NIHSS is insensitive for posterior stroke syndromes and are weighted more toward left-sided stroke syndromes given location of language centers