Grand Rounds Recap - 12/18/14

Morbidity and Mortality Learning Points with Dr. Stull

1. Should Post-ROSC patients get cardiac cath?

• Cardiac arrest patients who have STEMI on EKG after ROSC tend to have good outcomes (overall survival and intact neurologic survival) if they get cath'ed.
• According to latest Australian study (all patients with ROSC from OHCA, not STEMI) OR for overall survival is 2.77 and OR 2.2 for good neurologic outcome
• VT/VF cardiac arrest patients who do not have a  STEMI on EKG: improved survival and likelihood of good neurologic outcomes if cath'ed within 24 hours.
• Our cardiology department wants all post-ROSC VF/VT patients to have cath lab activation. All other post-ROSC cases, call cardiology to discuss need for cath lab
• All post-ROSC STEMI should go to cath lab no matter what their neuro status is

http://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/

2. Thrombolytics in STEMI

• PCI center: door to balloon goal is < 90 minutes
• Non PCI site: transfer with target door to balloon < 120 minutes
• If cannot have door-to-balloon < 120 min, need thrombolytics (goal within 30 minutes)
• Tenecteplase is preferred in STEMI: 1 time bolus over 5-10 seconds, weight-based dosing

3. Beta Blockers in STEMI

• Oral BB should be given within 24 hours: significant mortality difference. Level IB recommendation
• IIa: reasonable to give IV BB if the pt has a STEMI and no contraindications
• Contraindications: age > 70, SBP < 120, sinus tach > 110, bradycardia < 60 and prolonged symptoms (> 12 hours)
  • The higher the number of risk factors, the higher the risk of death

Other STEMI interventions:

• ASA: NNT 42 to prevent 1 death
• Plavix in cath lab: NNT 27 to prevent 1 MI/CVA, NNH 114 to cause major bleeding
• Integrillin: does not change patient centered outcomes, but does decrease need for repeat cath
• Thrombolytics: NNT 43 to prevent 1 death
• Mediterranean diet: NNT 30 to prevent mortality
• Older patients, women and diabetic with STEMI are more likely to present atypically
• Door to EKG standard nationally is < 5 minutes

4. Sepsis in Neutropenic Patients

• Cefepime is the first antibiotic that should be given (meropenem if allergic)
  • Pseudomonas is usually the predominant bug
  • May be different at different institutions, base decision on your local antibiogram
• Per heme-onc, all neutropenic patients (ANC < 500) with SIRS, regardless of fever, should be treated with cefepime
  • Caveat: antibiotic choice is very institution specific, so check with your shop when you leave UC
• Pay attention to diastolic BP
• Pulse pressure = SBP - DBP
• Wide Pulse pressure = large drop in DBP
  • Low SVR: sepsis, neurogenic shock, anaphylaxis, adrenal insufficiency
• Narrow pulse pressure = large drop in SBP
  • Decreased cardiac output: cardiogenic shock, obstructgive shock, hypovolemia

5. PRES: posterior reversible encephalopathy syndrome

By Rashmi Chawla, Daniel Smith and Paul E Marik [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

• Autoregulatory failure of cerebral vasculature and endothelial dysfunction
• No clear diagnostic criteria
  • HTN: Diastolic blood pressure is more important than systolic
  • Neurologic syndrome: HA, visual symptoms (especially hallucinations), confusion, seizures (usually presenting symptom)
  • Parieto-occipital white matter edema (MRI more sensitive)
• Treatment
  • Antihypertensives: nicardipine vs labetalol. Goal to reduce BP by 10-20%
  • Antiepileptic: phenytoin, benzo if actively seizing
• Caveat: not always posterior or reversible
• Difficult diagnosis to make, especially in ED. If considering PRES, admit to step down status

6. Scleroderma Renal Crisis

• Risk factors: rapid progression of early disease, steroid use
• Diagnosis: AKI, HTN (diastolic), encephalopathy, proteinuria, anemia (consumptive), pericardial effusion
• Treatment: ACE inhibitor

7. UTI/Bacteriuria in pregnancy 

• Asymptomatic bacteriuria in pregnancy needs to be treated regardless of symptoms: macrobid 100 mg BID for 5 days
• Send a urine culture
• Pyelonephritis in pregnancy = 56 fold increase in sepsis
  • Should be admitted
  • 1.3 fold risk of low birth weight infants and prematuriy

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Liver Disease and SBP with Dr. Lagasse

SBP is the most common complication of ascites with 6 month survival of 31%

• 30% of patients with ascites will have SBP

Pathophysiology of liver disease: hepatocyte death due to toxin or injury

• In chronic liver disease there is repeated scarring that disrupts normal liver parenchyma: nodular regeneration and congestion due to portal hypertension
• Liver failure: loss of metabolic and synthetic function

Pathophysiology of ascites: 

• Increased portal pressure drives fluid out of blood vessels
• Decrease in albumin production
• Na retention through RAS system

Pathophysiology of SBP: translocation of normal gut flora across bowel wall

• Due to bowel wall edema and poor immunologic function

SBP features

• Diffuse abdominal pain
• Consider SBP in all cases of new onset ascites or in ascites + another symptom

Paracentesis is diagnostic: cell count, glucose, protein, gram stain and culture

• Consider also getting albumin, LDH, cytology, tumor markers

Criteria for diagnosis: need just 1

• Neutrophils > 250
• WBC > 1000
• Positive gram stain or culture

Treatment: target E.Coli, proteus, Strep pneumo, enterococcus, anaerobes 

• Recurrence: based on prior culture
• New onset: Rocephin, cefotaxime, Zosyn, Unasyn, ticarcillin

Rocephin does not cover pseudomonas
Give albumin if removing > 5 L of ascites
SBP + Cr > 1 should receive albumin, as it will improve their renal function
FFP or platelets prior to paracentesis? Not recommended

• No clear cut offs for when you should transfuse prophylactically

Antibiotic prophylaxis should be given to cirrhotic patients who have upper gI bleeding
SBP prophylaxis in patients with ascites without GI bleeding: improves outcomes

• PO fluoroquinolones
• Patient's more likely to have resistant and aggressive bacteria if they develop SBP

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Non-Inferiority Studies with Dr. Doerning

Ethically this is more acceptable if there is a proven standard of care
There are 3 possible study designs for comparing 2 groups: 

1. Superiority: goal is to prove that the experimental group is better
2. Equivalence: experimental group equivalent
3. Non-inferiority: experimental group is not worse

Failure to show a difference does not mean equivalence
Nonsignificance does not mean 2 treatments are equal
Equivalence: usually used to compare generic drug to brand name drug

• Goal is to show absence of meaningful difference
• There is no test available that can show that 2 tests/drugs/interventions are equal

Non-inferiority (NI) studies are useful when:

• It is not ethical to do a placebo control study because there is a proven therapy
• Experimental group is not expected to be better than control on primary outcome of interest, but may have benefit in secondary outcome

Non inferiority margin: difference between control in NI trial and placebo in original trial

• Equivalence and non inferiority depend on a priori margins, it is important to know how margins are defined
• If your NI study is showing a benefit, you cannot actually report positive result because a priori you were looking for no difference
• Control drug used in NI trial should be widely used with established efficacy in superiority trials
• Non-Inferiority trial should be similar in design to original superiority trial in terms of sample size, confidence interval and randomization

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Ultrasound M&M with Pattie Smith, RDMS

Early pregnancy US

• Goals: Is there an IUP? Is there free fluid?
  • IUP = gestational sac + yolk sac/fetal pole
• Want full bladder on transabdominal and empty bladder for transvaginal scan
• Always prescan transabdominally
  •      - determine lie of uterus
  •      - is the bladder full or empty?
  •      - patient may be far enough along and you will not need a TV
  • - need to clearly see cervix in order to confirm that pregnancy is inside the uterus
• Interstitial/cornual (at intersection of tube and uterus) ectopic pregnancy can be confused with IUP
  • Looks like an IUP at the very edge of the uterus
  • If unsure, measure myometrial stripe - needs to be at least 6 mm
  • Do not anchor on the first thing you see, if you see a fetus with cardiac activity, keep looking to make sure it is inside the uterus
• Nabothian cysts: normal finding. Looks like small fluid pockets in the cervix and can be confused with IUP -> need to see the yolk sac!
• Zooming is generally not helpful as it degrades the image
  • Zoom is helpful if you see an embryo/yolk sac to look for cardiac activity

FAST

Pericardial fluid: on subxyphoid view will be between liver and heart; parasternal fluid will be posterior to heart

• If you are unsure on cardiac view, try doing a subxyphoid view with probe oriented longitudinally

RUQ view: must see both superior and inferior poles of kidney and inferior tip of the liver
LUQ view: need to see the spleen/diaphragm space as fluid will frequently collect there

• Ruptured spleen may have a falsely negative FAST as blood clots and will look similar to spleen parenchyma

Bladder view: should do both longitudinal and transverse views, but longitudinal is more sensitive

• Posterior acoustic enhancement from fluid-filled bladder may lead to false negative: turn down the gain

FAST should not be a definitive study to rule out intra-peritoneal hemorrhage: CT vs serial FAST vs serial H/H vs serial abdominal exam

When blood clots, it looks grey and can cause you to call a FAST falsely negative