Grand Rounds Recap 12/9/15

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Glucose Emergencies - Dr. Harrison

Remember the "I's" when looking for cause of DKA/HHS: Infection, Insulin lack, Infarction (MI, CVA, Ischemic gut), Indiscretion (EtOH, cocaine), Infant (pregnancy).

After 2L NS fluid bolus in the hemodynamically stable patient, the corrected sodium should guide fluid choice for further therapy.

Venous pH, HCO3 and base excess have sufficient agreement to be interchangeable with ABG in the ED.

Potassium derangement is one of the most common causes of death in DKA/HHS. Majority of patients have normal to hyperkalemia, however 10% will have hypokalemia. Wait for K+ to return before starting insulin therapy to prevent severe hypokalemia. Get an EKG.

Initial bolus of insulin was not associated with significant rate of change of glucose, improvement in anion gap or LOS in hospital. 

Review of HCO3 administration in DKA revealed: only transient improvement in acidosis, increased risk of cerebral edema, increased need for potassium administration and transient worsening in ketosis. Therefore, HCO3 therapy not currently recommened in patients with pH >/= 6.9.

R4 Capstone: IV Contrast Myths  - Dr. LaFollette

Contrast Induced Nephropathy (CIN)

  • 25% elevation in serum creatinine in the first 48 hours after IV contrast 
  • Peaks in 72 hours with a return to baseline usually within 7 days

What are risk factors for developing CIN?

  • Pre-exisiting CKD, CHF, diabetes, age > 70 and dehydration have all been implicated with varying strength

What are the issues with defining CIN?

  • People that have these risk factors are inherently SICK people
  • Sick people tend to get AKI at a much higher rate
  • Recent studies (McDonald et al) have been able to propensity match similarly pre-morbid patients and shown no difference, even in the lowest GFR group. Others have shown (Davenport et al) that GFR <30 (OR 2.97) is the only CKD group associated with CIN (still not a clinical outcome)

IV Contrast Use in Dialysis Patients

Concern for fluid overload

  • Normal contrast quantity for abdomen/pelvis CT is 100-150cc, unlikely to be the sole factor to tip someone into pulmonary edema
  • Check your contrast - normally used low osmolar omnipaque 350 (osm 884) is hyperosmolar, but you can request visipaque (osm 290) if you have concerns about potential fluid shifts - remember 3% hypertonic is 1027 osm so our default carries a heavy osmolar burden.

Need for urgent dialysis?

Lumbar Puncture - Dr. Murphy

The LP is not without complications, with the most common being headache.  There are several evidence based methods of decreasing post-LP HA:

  • Use a thinner needle
  • Use an atraumatic needle
  • Insert needle with bevel parallel to dural fibers
  • Replace stylet prior to removing needle

There are two studied methods for headache treatment once the patient already has a headache:

  1. IV Caffeine: effective, but its 500mg IV of caffeine
  2. Blood Patch: effective if performed within 24 hours of headache

LP and SAH:

  • Standard of care is still to CT first and then LP to rule out SAH
  • Recent literature questions this practice and suggests that at CT performed within 6 hours of the onset of headache may be sensitive enough to rule out SAH.  So know the literature and decide for yourself
  • Differentiating between a traumatic tap and a true SAH is difficult
  • One recent paper found that if the fluid had no xanthochromia and had RBCs < 2000 x 106/L in the final tube, you could rule out SAH.  Stay tuned for further research. 

EBM of ICH - Drs. Lagasse and Polsinelli

Highlights of the EBM recommendations include:

Imaging: followup CT with a CTA to detect underlying vascular lesions

Airway: if RSI indicated and time allows, pretreatment with esmolol and fentanyl is ideal.

BP:

  • Smooth consistent BP control is far superior to any rapid fluctuations.
  • If initial SBP is between 150 and 220, a goal of lowering SBP to < 140 within 1 hour is appropriate.
  • For SBP > 220, try for 25% reduction in the same time frame.

Anticoagulation Reversal:

  • Depends on the anticoagulant, but generally PCCs are going to be more effective and more rapid than FFP. See pathway for Factor Xa and Direct Thrombin Inihibitors. 
  • Consider DDAVP if patient is on an antiplatelet agent

Seizure prophylaxis is institution dependent, but Keppra for SAH is generally accepted

There is no clear evidence for tight glycemic control, nor an ideal glucose level

Case follow up - Dr. Toth

15 yo female on pyridium for 5+ days develops toxicity that results in methemoglobinemia and acute kidney injury.

Methemoglobinemia

  • Caused by some form of oxidate stress, typically is acquired secondary to medication use, and G6PD patients are 
  • Diagnosed by co-oximetry because normal blood gas and pulse oximetry cannot tell you the true oxygen carrying capacity of the hemoglobin or blood.
  • Approximate estimate for SaO2 = (100 - MeHgb level)
  • Treatment is methylene blue, 1-2 ml/kg over 5 minutes

Don't prescribe pyridium for more than 2-3 days.

EM-Peds Simulation and Lecture

High suspicion for omphalitis requires a full septic workup because of the high risk of bactermia. Bacteremia or CSF involvement will require a longer course of antibiotics.

Simulation involved the hypoxic neonate with poor tone. The patient ultimately required positive pressure ventilation with a diagnosis of bronchiolitis, but consideration and early treatment of sepsis is advised.