Article: Hypotonic maintenance IV fluids in pediatrics

IVbags2 copyA 6-month-old male presents to the emergency department with diarrhea and vomiting. Despite antiemetic therapy, the the child is unable to tolerate oral intake in the ED and so you opt to admit him to the hospital for IV fluids.  The pediatric hospitalist requests that you write maintenance fluids prior to admission to the floor. Utilizing the 4-2-1 rule you calculate maintenance needs and choose D5 ½NS as your fluid. This is what you had been taught to utilize in children. It seems appropriate… but is it?

Background

Holliday and Segar published their seminal work on the maintenance caloric and fluid needs of children in Pediatrics in 1957 [1]. As the paper utilized hypotonic solution to match presumed solute needs, subsequent generations of emergency physicians and pediatricians have relied upon hypotonic solutions to serve as the primary vehicle for which to deliver caloric and electrolyte needs. The original calculations recommended 0.2% saline however this has largely been supplanted by 0.45% saline with dextrose as a primary intravenous maintenance fluid. Though D5 0.45% saline is chemically hypertonic, in vivo it is an effective hypotonic solution due to the rapid uptake and metabolism of dextrose. 

Recently there have been a few trials (reviewed in the systematic review we are discussing) that question the wisdom of using hypotonic solutions as maintenance fluid. It is theorized that hospitalized and critically ill children may have a non-osmotic stimulus for anti-diuretic hormone secretion potentially leading to hyponatremia and/or cerebral edema.    

Article Citation

Foster BA, Tom D, Hill V. Hypotonic versus Isotonic Fluids in Hospitalized Children: A Systematic Review and Meta-Analysis. J Pediatr. 2014 Feb 27. PMID:  24582105

Objective 

  • Systematic review of all studies comparing isotonic to hypotonic maintenance fluids in chilren assessing for hyponatremia

Study Methods 

  • Cochrane style systematic review in which a total of 10 studies met inclusion criteria and were included in the final analysis
  • 5 ICU studies, 4 ward studies, 1 mixed study
  • Patients had variety of illness (many were very sick) 
    • Large representation of PICU and post-operative patients 
  • Multiple different hypotonic fluids included across studies including 0.18%, 0.3%, and 0.45% saline
  • Primary outcome: hyponatremia (Na <135 mmol/L)
  • Secondary outcomes: 
    • Change in serum sodium from baseline
      • Moderate (<130 mml/L)
      • Severe (< 125 mmol/L)
    • Adverse events of hypernatremia (> 145 mmol/L)
    • Mortality

Results 

  • 11 RCTs included
  • Primary outcome
    • Relative risk for hyponatremia = 2.37 (1.72-3.26)
    • Assuming an estimated control event rate (CER) for hyponatremia of 5%, the Number Needed to Harm (NNH) = 15 (9-28)
    • Assuming an estimated CER for hyponatremia of 20%, the NNH = 4 (3-7)
      • The calculations of these NNHs are based upon the varying CER found in the various studies.
        • The control event rate describes how often an event in study occurs within the control group
        • To determine the NNH (as the NNT) we utilize the control event rate and the experimental event rate (EER—how often the event in study occurs in the treatment group).
          • NNH= 1/(EER-CER)
      • The authors utilized both the high and low end of the CER to give a range of NNH (4-15) with corresponding confidence intervals (3-28) depending upon the CER 
  • Secondary outcome
    • Change in serum sodium (5/11 studies described this statistic) = -2.46 (-3.11 to -1.81)
    • Mortality: none identified
    • Relative risk for hypernatremia (8/11 studies described this statistic) = 0.81 (0.32-2.04)
      • Reported about 0-6% incidence of hypernatremia using isotonic fluids
      • NNH not calculated due to nonsignificant findings 

Analysis

The studied population, that which the systematic review included, was heterogeneous and included disparate disease states lumping together floor patients admitted for various reasons with post-operative patients admitted to the PICU setting.  Though the underlying question of hyponatremia in the entire cohort may be equivalent (the I2 statistic did not demonstrate significant statistical heterogeneity) it may also be the case that sicker and post-operative patients have altered physiology from increased disease burden and represent the primary population in which ADH excess is triggered by non-osmotic stimuli (the actual at risk cohort).   

Due to the few studies included with routine pediatric EM admissions (e.g. dehydrated gastroenteritis) it is difficult to secondarily generalize these findings into the ED setting. It is also worth noting that there were no disease oriented outcomes delineated in either group from shifts in serum sodium concentrations. Though hyponatremia may predict subsequent neurological deterioration and cerebral edema, this systematic review did not find deleterious patient responses either because they do not occur or they are rare enough to not be found in the final analysis.  

Future Directions

This article forces us to reassess conventional wisdom in the light of new experimental evidence. Hypotonic maintenance fluids were originally established using a now 60 year old study on the basis of presumed rather than clinically confirmed patient physiology. While this particular systematic review failed to find patient oriented harm associated with hypotonic maintenance fluids it did show an absolute alterations in serum sodium potentially predictive of poor patient outcomes.

The next step will be to verify the study results and make it more applicable to our ED patient population. A prospective study of pediatric ED patients admitted for disease entities requiring maintenance fluids could be undertaken comparing the two intravenous fluid tonicities, using laboratory and clinically relevant outcome measures.  

References

  1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957 May;19(5):823-32. PMID: 13431307.

Author information

William Paolo, MD
William Paolo, MD
Residency Program Director
Assistant Professor of Emergency Medicine
SUNY-Upstate Medical Center

The post Article: Hypotonic maintenance IV fluids in pediatrics appeared first on ALiEM.

Basics of Blogging at 2014 CORD Academic Assembly

images

Turns out New Orleans is a fantastic city, not just for the food and culture, but also as a setting for the 25th anniversary year of the Council of Residency Directors Academic Assembly conference (CORD). The ALiEM crew was on hand to help teach a pre-conference workshop called #DontGetLeftBehind: FOAMed and Social Media for EM Educators, dedicated to learning tricks of the trade of the different modalities of social media for medical education. Naturally we focused our section on blogging. Rather than let all that information go to waste, we have shared our work in this post in the true spirit of collaboration! 

Our session was headlined with the sage and wise cracking Dr. Joe Lex (@JoeLex5)  with the best quote of the session, “Hippocrates believed in #FOAMed even before it existed!” We paired with leading national experts on social media and education who taught various platforms: Twitter (@JohnGreenwoodMD), wiki (@EMEducation), podcasting (@EMSwami and @Embasic). Joining us in our blog session was Dr. Adaira Landry (@AllAroundDoc), one of the creators of emdocs.net.

Used a blog to teach and learn about blogging!

For the workshop, we created a “dummy” website using the free WordPress.com service. This site not only hosted brief instructor how-to guides but also provided an actual blog space for workshop participants to practice blogging with the assistance of established bloggers. After learning how to add images, embed video, creating hyperlinks, and building tables, the workshop attendees began to see the potential for this versatile communication medium especially in medical education. We hope to have sparked the imagination!

Blog site: Cord2014.wordpress.com



Instructional blog posts topics include: 

  • How to add a PDF and an image
  • How to embed a YouTube video
  • How to create a simple table
  • How to create a Twitter widget in right column
  • ALiEM’s working document on how to write a blog post

Of note, the information provided on this post refers to the free WordPress.com website. As such, many advanced and customized features are not available on the free site. For this reason, ALiEM uses a self-hosted WordPress.org site.

A recent post from emdocs.net goes through the pearls from the other sections of the workshop including Podcasting, Twitter, and Wikis.

Good luck, enjoy! Please contact us if you have any questions!

Author information

Nikita Joshi, MD
Nikita Joshi, MD
ALiEM Associate Editor
Editorial Board Member
Academic Fellow
Stanford University, Division of Emergency Medicine

The post Basics of Blogging at 2014 CORD Academic Assembly appeared first on ALiEM.

Beware of fluoroquinolones: You, your patient, and the FDA

LevofloxacinFluoroquinolones are a widely used class of antibiotic that are effective in treating a wide variety of infections. Despite their popularity there is increasing concern regarding to the potential complications associated with these agents. In 2008, the U.S. Food and Drug Administration (FDA) issued a black box warning involving fluoroquinolone use and an increased risk of tendon rupture. More recently in 2013 the FDA released another warning regarding the risk of peripheral neuropathy and required additional warnings to be added to the drug labels [1].

Tendinopathy: How it became a black-box warning

Starting in the early 1980s, case reports began to emerge that attempted to connect fluoroquinolone use to the increased risk of Achilles tendinopathy [2]. In 2003, a WHO survey performed in Australia reported an increase in tendon rupture in patients taking fluoroquinolones and found ciprofloxacin to be the culprit in ~90% of cases [3-4]. Since then similar reports of tendon rupture have emerged involving a wide range of fluoroquinolones [5]. In 2008, the FDA issued a black-box warning for all fluoroquinolone products that indicated an increased risk of tendon rupture in patients taking these agents [6].

Peripheral Neuropathy: How it became a warning

Fluoroquinolones have carried a warning regarding the risk of peripheral neuropathy since 2004. In 2013, after reviewing several years of reports from the Adverse Events Reporting System, this warning was enhanced. While the exact incidence of these events is somewhat unclear, often peripheral neuropathy developed after only a few days of treatment and at times could continue chronically [1].

What exactly is the risk for the patient?

When compared to the general population, patients taking fluoroquinolones have a 4.1 fold increased rate of Achilles tendon rupture. This risk is increased in:

  • Men
  • Age > 60 years
  • Chronic renal disease
  • Taking corticosteroids - there is a 46 fold increase in the rate of tendon rupture when compared to age-matched controls [7] 
  • Recipients of solid organ transplants

Typically symptoms of tendinopathy will start about 6 days after the onset of treatment, yet the risk of tendon rupture remains elevated for up to 90 days, with over 50% of patients experiencing symptoms that began after their treatment was completed [8].

The risk factors associated with fluoroquinolone use and peripheral neuropathy are still somewhat unclear. Providers are advised to monitor all patients for any signs of nerve damage including pain, numbness, weakness, or changes in sensitivity to pain or temperature [1].

What is the risk to the provider?

Lawsuits related to complications from fluoroquinolones are increasing. In recent years, levofloxacin has come under particular scrutiny as its popularity has increased. In 2010 a jury awarded $1.8 million to an 82 year old man who experienced bilateral calcaneal tendon ruptures after taking levofloxacin. As of 2011 there were over 2,500 lawsuits pending with regards to tendon rupture in the setting of fluoroquinolone use [9]. As FDA warnings in regards to neuropathy are published, there will likely be a rise in related lawsuits.

So should we stop prescribing fluoroquinolones?

Fluoroquinolones remain an effective antibiotic that can be used to treat a wide variety of conditions. In patients with community acquired pneumonia, there is growing resistance to macrolide therapy and several guidelines now recommend respiratory fluoroquinolones as the first line agent of choice [10]. Additionally, fluoroquinolones are suitable for patients who are allergic to penicillin, and are also available in once daily dosing [11]. While the risk of complication from these antibiotics cannot be ignored, they are arguably the drug of choice to treat a variety of infections.

How to limit your risk

Provider risk is increased any time medications are used that carry significant FDA warnings. Despite this risk, in certain clinical situations, the relatively minor risk of tendinopathy is vastly outweighed by the benefit offered by this class of antibiotics. The FDA warning advises providers to avoid using fluoroquinolones in patients who have a high risk of tendon rupture. When prescribing these medications, providers should have a discussion with the patient involving the associated potential risks and benefits. In addition providers should advise patients to limit high impact physical activity and should discuss signs and symptoms of tendon injury that should prompt an immediate return to the ED. If a patient presents with any signs of tendon injury after taking fluoroquinoloes, the medication should be stopped immediately and an alternative class of antibiotics should be used.

Documenting a clear discussion of potential risk and benefits of using fluoroquinolones is a crucial step to minimize risk in the event of a bad outcome. Given the fairly substantial FDA warnings associated with this class of drug, some emergency departments have developed standardized warnings to place in the chart anytime a patient is prescribed a fluoroquinolone.

I am prescribing a fluoroquinolone for the patient to treat their pneumonia. I have discussed the risks associated with this medication including risk of tendon rupture and neuropathy. I have considered other classes of antibiotics and I think this is the most appropriate choice of medication.The patient has verbalized an understanding of these risks, has been advised to limit strenuous exercised while taking these medications, and will return immediately for any pain, swelling or if they develop any new or concerning symptoms. 

With the increasing number of cases being filed in response to fluoroquinolone-associated complications, providers should be aware of the significant medicolegal risk that can accompany the use of these medications. While fluoroquinolones remain an effective and reasonable choice of antibiotics, when using these medications providers should discuss and clearly document potential risks and benefits with all patients. 

This post belong’s to Dr. Matthew DeLaney’s series on Everyday Risk in Emergency Medicine (EREM).   

References

  1. Food and Drug Administration: Drug safety announcement about fluoroquinolones and possible peripheral neuropathy (Aug 15, 2013) [PDF, 119kb] 
  2. Bailey RR, Kirk JA, Peddie BA. Norfloxacin-induced rheumatic disease. NZ Med J. 1983;96 (736): 590. Pubmed
  3. Gültuna S, Köklü S, Arhan M et-al. Ciprofloxacin induced tendinitis. J Clin Rheumatol. 2009;15 (4): 201-2. Pubmed
  4. Williams RJ, Attia E, Wickiewicz TL et-al. The effect of ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism. Am J Sports Med. 28 (3): 364-9.  Pubmed
  5. Akali AU, Niranjan NS. Management of bilateral Achilles tendon rupture associated with ciprofloxacin: a review and case presentation. J Plast Reconstr Aesthet Surg. 2008;61 (7): 830-4.  Pubmed
  6. Food and Drug Administration: Information page about fluoroquinolones for healthcare professionals (updated August 15, 2013). 
  7. Corrao G, Zambon A, Bertù L et-al. Evidence of tendinitis provoked by fluoroquinolone treatment: a case-control study. Drug Saf. 2006;29 (10): 889-96. Pubmed
  8. Royer RJ, Pierfitte C, Netter P. Features of tendon disorders with fluoroquinolones. Therapie. 49 (1): 75-6. Pubmed
  9. Klauer K. Fluoroquinolones: The risk behind the drug. Emerg Phys Monthly (August 18, 2011).
  10. Viasus D, Garcia-vidal C, Carratalà J. Advances in antibiotic therapy for community-acquired pneumonia. Curr Opin Pulm Med. 2013;19 (3): 209-15. Pubmed
  11.  Stahlmann R, Lode HM. Risks associated with the therapeutic use of fluoroquinolones. Expert Opin Drug Saf. 2013;12 (4): 497-505. Pubmed

Image

Update 4/8/14 at 23:30 PST

While we at ALiEM appreciate patient insight into this topic, we are primarily a website targeting medical professionals only. We will be limiting comments to just from medical providers. We at ALiEM mean for the site to be a safe place for providers to share opinions and discuss scientific issues. Personal attacks on commenters will be removed because they are not in the spirit of this educational blog. That being said, we will be leaving up all the other patient-perspective accounts as of this time. Thank you all for sharing your stories.

Author information

Matthew DeLaney, MD
Matthew DeLaney, MD
Assistant Professor of Emergency Medicine
Assistant Medical Director
University of Alabama at Birmingham

The post Beware of fluoroquinolones: You, your patient, and the FDA appeared first on ALiEM.

MEdIC Series: The Case of the Humorous Humerus – Expert Review and Curated Commentary

UnProfessionalismThe Case of the Not-So-Humorous Humerus presented an attending faced with a patient complaint about a resident. This is a situation that all of us will almost certainly be faced with at one point or another and there is no easy way to address it. This month we asked you to tell us how you would approach this difficult conversation to successfully determine what the problem was and how it should be addressed.

 

This month Dr. Amy Walsh (@docamyewalsh) and I (@TChanMD) explored this issue with insights from the ALiEM community and 2 experts.

This follow-up post includes:

  • The responses of our medical education experts, Drs. Felix Ankel and Anne Smith
  • A summary of insights from the ALiEM community derived from the Twitter  and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

Expert response 1: Compassion Fatigue & Feedback

Felix Ankel, MD
VP and Executive Director, Health Professional Education, HealthPartners Institute

This case is common and offers the learner a teachable moment in communication and situational awareness and the teacher an opportunity to hone the skills of feedback, cadence, and maintenance of boundaries.

Jack Ende’s 1983 JAMA article “Feedback in Clinical Medical Education” remains a classic and offers eight goals of effective clinical feedback (1). He suggests that feedback should:

  1. Be undertaken with the teacher and trainees working as allies with common goals
  2. Be well-timed and expected
  3. Be based on first-hand data
  4. Be in small quantities and limited to behaviors that can be remediated
  5. Be in descriptive non-evaluative language
  6. Deal with specifics, not generalities
  7. Offer subjective data labeled as such
  8. Deal with decisions and actions, rather than intentions or interpretations

Communication with the resident in this case may be influenced by the opening and cadence of the feedback. Consider opening with a soft invitation for feedback. For example:  “Can I give you some feedback based on the information I received from Mrs. Johnson”.  If an agreement to discuss Mrs. Johnson has been reached, I suggest limiting the feedback to the facts of the case and ask for Dr. Peter’s reflection. Based on the reflection, the attending may see the depth of Dr. Peter’s insight and adjust the cadence of subsequent feedback.

If Dr. Peters shows deep insight, I suggest the attending coach the resident on the anatomy of a patient apology and have a further discussion after the shift. This would be a better time to discuss compassion fatigue and situational awareness. Depending on the circumstance, a more in depth discussion could open the door to further discussion on depression, substance abuse, and personal relational challenges. If Dr. Peters shows limited insight, the attending should set guidelines for expected behaviors with clear consequences and discuss his concerns with the program director if continued communication issues occur.

Some programs are attempting a residency culture shift towards compassion through design thinking (2). Some have incorporated Schwartz Center rounds (3,4), an interdisciplinary forum where attendees discuss psychosocial and emotional aspects of patient care (5). Others have partnered with the Institute of Patient and Family Centered Care(6), which offers resources and patient advisors to programs wishing to embark on a patient centered journey.  Ultimately the combination of a residency culture focused on compassion with consistent 1:1 individual resident feedback will lead to residents with superior patient communication skills.

References:

  1. Ende J.  Feedback in clinical medical education. JAMA 1983 250:777-781.
  2. Design Thinking, Wikipedia.
  3. Lown B, Manning MA. The Schwartz Center Rounds: Evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Academic Medicine 2010 85:1073-1080
  4. Schwartz Center Rounds. The Schwartz Center. Retrieved on March 17, 2014.
  5. Ankel, F. Royal College Program Director Podcast. International Conference on Residency Education. Retrieved on March 17, 2014.
  6. Institute for Patient and Family Centered Care. Retrieved on March 17, 2014.
  7. Fox R. Cultural Competence and the Culture of Medicine. NEJM 2005:353;1315-1319

Expert response 2: Seven Tips for Improving the Patient Experience

Anne Smith MBChB  FCEM(SA)  MMed
Emergency Physician and Educator, Cape Town, South Africa

The discussion points in this case hinge around three main topics:

Patient expectations:
Patient expectations vary with age, gender, cultural background and previous medical history. Some expect or associate physical touch with a more ‘caring’ doctor, while others would prefer not to be touched unless being examined. Some prefer a more conversational style of consultation while others would engage more with a more formal, fact based type of consultation.

One of the skills we must learn as EM clinicians is how to quickly make our patients feel comfortable and trusting of our clinical skill and decisions. We don’t have the luxury of time to build long term relationships – we are expected to delve into peoples’ most intimate secrets after only a few minutes! We work in clinical areas that are often busy, noisy, filled with distractions and not very private. Our attitudes and personal communication skills go a long way towards putting our patients at ease.

Our patients have right not only to excellent medical care and appropriate diagnoses, but also to a pleasant human experience while in our care.

Doctors attitudes:
Sometimes it is hard to explain why we feel the way we do towards our patients.  We need to be aware of how our own prejudices and personal issues may affect our consultation and decision making skills. If we are is tired, hungry or had a previous negative experience with a particular type of patient, this may adversely affect their attitude towards them.

Compassion fatigue may result from external factors (long working hours or heavy on call duties) and internal factors (personal mental health issues or physical illness). It is our responsibility as educators and mentors to watch for evidence of compassion fatigue in those working with us and to address problems before patients suffer.

Cognitive errors:
We all make cognitive errors during consultation, particularly when we lapse into intuitive thinking rather than deliberative thinking.  These errors may get worse in busy units, or with physical stressors like lack of sleep.

One example of a cognitive error in this case is anchoring, or anchor bias: Sean may have decided early on this consultation that she didn’t have a fracture and that the x-ray would be done simply to appease the patient. He may have neglected looking for other potential complications that a fracture could cause as he had already decided this was a ‘deep bruise’.

In summary:

You can try some of the following to improve your patient experience:

  1. Introduce yourself and your role in the ED: It sounds simple, but it is easily forgotten.
  2. Ensure that the patient is comfortable before you start your consultation and try maintain their dignity and privacy as much as possible,
  3. Listen to the patient and let them tell the story in their own words. This can be frustrating, but interrupting and asking closed-ended questions may cause us to miss critical information.
  4. Practice self-reflection: During and after the consultation, ask yourself how you think it is going/went and what the patient is experiencing. Note any irritation or distraction in yourself and try to pinpoint why you are feeling that way and how it is affecting your patient contact.  Physical stressors like hunger and tiredness, as well as psychological stressors like a full waiting room may impact your bedside manner.
  5. Practice with simulation: This case  could easily be practiced in a role-play or simulation scenario.
  6. Beware of ‘difficult’ patients: Patients labeled or perceived as ‘dramatic’, ‘demanding’ or ‘uncooperative’ can blind us to their actual pathology and prevent us from getting a good history and examination.
  7. Use checklists, mental ‘checkpoints’ and senior advice to prevent or minimize cognitive error.

References:

  1. Croskerry P, Abbass A, Wu AW.  Emotional influences in patient safety. J Patient Saf. 2010 Dec;6(4):199-205.
  2. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.
  3. Block L, Hutzler L, Habricht R, Wu AW, Desai SV, Novello SK, et al. Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. J Hosp Med. 2013 Nov;8(11):63-4.

The Case of the Not so Humorous Humerus: Curated from the community

Curated by Teresa Chan

The following are some themes that emerged from our discussion in the case comments for this past week.

1. Explore the resident’s point of view and context

Unless there was a CCTV camera in the room, you’re probably never going to really know what happened between Sean and his patient, but as a faculty member you probably should explore this a bit. Most respondents felt it was important to explore the perceptions of both involved parties. Drs. Walsh, Rogers, Thoma and Chan all noted that it is imperative to listen to what the resident (Sean Peters) had to say about the situation. Dr. Rogers wisely noted that “…sometimes patients “split” the providers and give different stories” while Dr. Thoma stated that until the resident has had an opportunity to explain any explanations will be as flawed as the assumptions they rest on.

As an outpatient geriatrician, Dr. Michelle Gibson raises a point that there may be some inherent cultural biases that may occur that lead to scenarios like this one. She notes the response the resident, Dr. Peters, displays may be a symptom of a bigger underlying problem with the ‘hidden curriculum’ (i.e. he may act a certain way because he have seen others act a certain way around patients who did not turn out to have a “legitimate” injury, etc..)

2. Provide the opportunity to reflect back… it may provide you a window into their world.

Most respondents brought up that as an educator you should ask the resident what his perceptions of the interaction were.  Listening to the resident’s perception of the situation will give you great insight into how best to approach the issue; if he shows insight, then you can discuss and debrief the ‘root causes’ of the professionalism transgression.

Some suggested contributing factors to this breach of professionalism were:

  • Compassion fatigue
  • Depression
  • Substance Abuse
  • Counter-transference
  • “Attribution error”
  • Personality Conflict
  • Problems outside the workplace (i.e. relationship issues)

3. Don’t shy away from the feedback

Every mistake or problem in training gives us the chance to feedback and improve, so many respondents felt that this provided us a unique opportunity to provide constructive guidance and feedback to the resident (Dr. Peters), but more importantly, it allows him to encounter this problem now as a trainee. As Dr. Nadim Lalani notes: “This interaction was a gift from the ER gods. There’s only one way to learn some skills in life. Mistakes like this offer the R3 an opportunity to learn and change.”

Feedback is important and, as Allan McDougall (a social science researcher) highlights, is often highly shaded by our “culture of training”.  He describes the work of Watling et al. (1), which he felt was relevant to this issue around providing feedback:

“…feedback is only effective insofar as the receiver considers the provider to be credible and constructive. Further, definitions of credibility and constructiveness vary according to the learning culture (e.g., a music teacher may be highly critical of a student’s posture, but that type of directness is valued in music; while a medical teacher may need to approach feedback in a different way, as we are discussing here).”

When compared to other disciplines (e.g. education and medicine), the value of feedback can be highly susceptible to cultural nuances – and Allan goes on to warn us about paying attention to our own local cultural nuances.

More broadly, Dr. Rob Rogers made a bold but important statement:

“I would emphasize that we owe it to our learners to keep track of this behavior and not dismiss it as an isolated event, unless it really is. This might require discussing with the program director, etc. We owe it to our patients and our learners to make sure we are doing all we can to train competent professionals. Too many times we dismiss such isolated events and never follow up. Learners with significant issues can ‘slide under the radar” for quite sometime if we don’t stay on top of things.”

4. Remember the patient

In clinical teaching, patient care is paramount.  Many respondents suggested that it is very important to have Dr. Peters apologize for the situation. As such, several esteemed respondents reminded us that it is important to arrange for Dr. Peters to apologize to the patient. Of course, this would necessitate that Dr. Peters agrees (or at least accepts) the patient’s version of proceedings.  In any event, empathizing with the patient is important – and this may be an opportunity for you to role model how to deal with this type of situation.

Dr. Michelle Gibson writes about her approach to this:

“This is the biggest learning opportunity, I think. I have asked residents to address patient concerns about encounters. We usually talk about how to approach it before hand, and then I go in and directly observe. If they do a good job of this, I make sure they know that they handled it well. I think that it usually turns it into a very, very powerful learning experience and (in my opinion anyway…) may be the thing that is most likely to help it not happen again.

As we do not have the opportunity as Dr. Gibson has to discuss encounters again later with most of our patients, it is important to act in a timely manner during that visit.

Reference:

1.  Watling C, Driessen E, van der Vleuten CP, Vanstone M, Lingard L. Beyond individualism: professional culture and its influence on feedback. Med Educ. 2013 Jun;47(6):585-94.

 

Case and Responses for Download

Click Here (or on the picture below) to download the case and responses as a PDF.

MEdIC Mini PDF picture

Author information

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Clinical Scholar, McMaster University
Ontario, Canada

The post MEdIC Series: The Case of the Humorous Humerus – Expert Review and Curated Commentary appeared first on ALiEM.

High Sensitivity Troponin T and Acute Myocardial Infarction: One and Done?

acute-coronary-syndromeExpertPeerReviewStamp2x200There has been a lot of publicity about evaluation of chest pain patients in the emergency department (ED) with high sensitivity troponin testing. In the past with older troponin assays, clinicians would evaluate patients, get an ECG, and an initial set of cardiac biomarkers. The subsequent set of biomarkers would be performed at 6-8 hours later before determination of disposition. In the past few years, several studies have been published evaluating point of care troponins,  sensitive troponins, and high sensitivity troponins which have changed our practice and evaluation of these patients.  An early version of a study was recently released in the Journal of the American College of Cardiology (JACC) stating that for ED chest pain patients, we may be able to discharge patients from the ED with an initial normal ECG and single high sensitivity troponin T (hs-cTnT). So is it true… one and done?

Google Hangout on Air with Dr. Holzmann

 

Citation: High Sensitivity Troponin T study

Bandstein N, Ljung R, Johansson M, Holzmann MJ. Undetectable high sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Card. 2014 [Free PDF of early online release]

What they did:

  • Retrospective study of 14,636 patients age ≥ 25 years presenting to an ED with chest pain, with at least one hs-cTnT and ECG over two year period in Stockholm, Sweden
  • Compared patients with hs-cTnT of < 5 ng/L, 5 to 14 ng/L, and > 14 ng/L

Primary and Secondary Outcomes:

  • Primary Outcomes: Fatal or non-fatal type 1 MI within 30 days of ED visit
  • Secondary Outcomes: MI within 180 days and 365 days after the ED visit
  • Also calculated hazard ratio for all-cause mortality in patients with first hs-cTnT of < 5 ng/L for admitted versus directly discharged from ED patients

Results:

  • Myocardial InfarctionMean age of 55 years old
  • 61% (8,883 patients) of patients had initial hs-cTnT < 5 ng/L
    • 39 had diagnosis of MI and 2 died at 30 days
      • 15  of these 39 had no ECG changes
  • 21% of patients had initial hs-cTnT between 5 – 14 ng/L
  • 18% of patients had initial hs-cTnT > 14 ng/L
  • Hospitalization rate of 21% in patients with initial hs-cTnT < 5 ng/L
    • 90% of these patients had a second hs-cTnT < 5 ng/L 
    • 10% of these patients had a second hs-cTnT of between 5 – 14 ng/L or > 14 ng/L
    • 14% of patients were discharged home with diagnosis of MI
  • If initial hs-cTnT < 5 ng/L AND ECG with no signs of ischemia:
    • NPV for MI and death at 30 days 99.8% and 100%, respectively
    • Absolute risk for MI 0.17%
    • No significant difference in the risk of death within 365 days between patients discharged directly form the ED vs admitted to hospital (HR 0.73 with CI 0.48 – 1.12)

Limitations:

  • Retrospective study
  • No external validation study

Author’s Conclusion: Patients with chief complaint of chest pain presenting to the ED with an initial hs-cTnT of < 5 ng/L and no signs of ischemia on ECG have minimal risk of MI and/or death at 3o days and can be safely discharged from the ED.

My Thoughts: Sensitivity vs Specificity

15 of 8,883 (0.2%) patients had a diagnosis of MI with initial hs-cTnT of < 5 ng/dL. But on the flip side only 676 of 2,579 (26%) patients with a hs-cTnT > 14 ng/dL had a diagnosis of MI at 30 days. Another way of stating this is the significance of a positive test is significantly reduced with higher sensitivity troponins (i.e. for what we gain in sensitivity we are giving up in specificity).

From a practical standpoint, would you then admit all your patients with indeterminant hs-cTnT’s (i.e. ≥ 5 ng/dL), knowing that the majority of these patients don’t have an AMI? The Associated Press recently published:

Dr. Allan Jaffe, a cardiologist at the Mayo Clinic, said the problem is not what the test rules out, but what it might falsely rule in. It’s so sensitive that it can pick up troponin from heart failure and other problems and cause unnecessary tests for that.  

I look forward to seeing additional followup studies looking at hs-cTnT utility and generalizability. 

For more thoughts, also check out:

Expert Peer Review

April 3, 2014

Salim does a great job reviewing this study and points out a number of weaknesses here. Whether we like it or not, hscTnT is coming to an ED near you (if it hasn’t already) and we need to understand the test and how to use it. This test is extremely sensitive. No one argues this point. Unfortunately, as with all tests, a high sensitivity comes with the cost of a poor specificity. A lot of patients will have intermediate or high levels that don’t have disease. These patients will be subjected to further testing. The further testing may simply be a second troponin but could also be CTCA or cardiac catheterization. These tests come with numerous risks and minimal benefits.

Goldstein et al demonstrated that patients who got CTCA instead of traditional care had a 4-fold risk of invasive interventions without an improvement in important outcomes [1]. deFilippi et al. showed the same results when comparing stress test to cardiac catheterization in 2001. The group that went right to cath had an 11% revascularization rate as compared to 4% in the stress group with no change in patient centered outcomes [2]. Additionally, revascularization for patients without STEMI has been shown to be without benefit by both the Cochrane group in 2010 and by Stergiopoulos et al in 2012 [3,4].

What does this study add to the discussion? One huge take home is that ECG findings should not be ignored. In the small group (n = 39) of patients with a hs-cTnT < 5 ng/L who had MIs, 24 of them had ECG changes. We must be vigilant about reviewing the ECG regardless of the type of troponin assay we are using. If you have a negative hs-cTnT and negative ECG, patients can go home but can we get there without this test? I argue that we can for many patients. Skeptics of our clinical abilities often quote the Pope article in NEJM in 2000 that we have a 2% “miss rate” for MI. In that study, 19 patients with MIs were sent home out of 11,000 ED patients with chest pain. That’s actually a miss rate of 0.18% (the same miss rate quoted in Bandstein study) [5]. Yes, we missed 2% of the 900 MI patients but that doesn’t take into account all the other patients with chest pain. I think the 2% number is misleading and leads us to marginalize our skills. 

The bottom line here is that the hs-cTnT isn’t an evil test but it will become the bane of our clinical existence if we treat like a panacea to chest pain admissions. This test, as all others, must be applied to the correct group of patients. We must prognosticate before we start diagnostic workups. Worster and colleagues eloquently make this plea in their editorial in Annals in 2012 [6]. We as a specialty need to make sure that the hs-cTnT doesn’t become the d-dimer of this decade.

References

  1. Goldstein JA et al. A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain. JACC 2007; 49(8): 863-871.
  2. deFilippi CR et al. Randomized Comparison of a Strategy of Predischarge Coronary Angiography Versus Exercise Testing in Low-Risk Patients in a Chest Pain Unit: In-Hospital and Long-Term Outcomes. JACC 2001; 37(8): 2042-9.
  3. Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era (Review). Cochrane Database Syst Rev 2010; 17(3)
  4. Stergiopoulos K, Brown DL. Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease. Arch Int Med 2012; 172(4): 312-9.
  5. Pope JH et al. Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department. NEJM 2000; 342: 1163-70.
  6. Worster A, Kavask PA, Brown M. Risk Stratification in the Era of High-Sensitivity Troponin Assays. Ann Emerg Med 2012; 59(2): 126-7.

 

Author information

Salim Rezaie, MD
Salim Rezaie, MD
ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews

The post High Sensitivity Troponin T and Acute Myocardial Infarction: One and Done? appeared first on ALiEM.

Uncomplicated Urinary Tract Infections in Older Adults: Diagnosis and Treatment (Part 2)

abxIt seems like a simple enough question: How do you diagnose and treat uncomplicated urinary tract infections (UTIs) in older adults? The answer is: It depends. In Part 1 of this post we discussed the diagnosis of UTIs in cognitively intact older adults and those with underlying cognitive impairment. This post will discuss treatment options.

UTIs are the most common bacterial infection diagnosed in older adults (age 65 and over) [1]. They are the most common reason for antibiotic use [2] and account for 5% of ED visits in this population [2]. Remember from part 1 that asymptomatic bacteriuria is very common in older adults, and does not require treatment. Furthermore, pyuria with or without bacteriuria is also common in asymptomatic older adults, particularly those with chronic incontinence [3]. The key to distinguishing a UTI from asymptomatic bacteriuria (ASB) is the patient’s symptoms. Also remember, that in older adults a male patient with a UTI is considered complicated, as well as patients with pyelonephritis, sepsis, indwelling catheters, or recent instrumentation. As with anything in medicine, there are risks and benefits to treatment. The benefits include relieving symptoms, and preventing progression of the infection to pyelonephritis or baceteremia. However, overuse of antibiotics can breed resistant bacteria, and the medications we use (as will be detailed below) are not without side effects. If it is clearly a UTI, then give antibiotics. If it is clearly asymptomatic bacteriuria or pyuria, then don’t. If you are not sure, and the patient or their care-giver are reliable, you could consider a wait-and-see approach in which you give a prescription, and instruct them to fill it only if the patient develops symptoms. Or, if the patient has good follow up, you could have them rechecked after 2 days, once the urine culture is completed.

Treatment of Uncomplicated UTIs

Once you have determined the patient does have an uncomplicated UTI, you have to decide how to treat them. E. coli are by far the most common bacteria isolated in community dwelling older adults (75-82% of UTIs) and nursing home residents (54-69% of UTIs). Proteus, Klebsiella, and Enterococcus species account for most of the remaining infections [2]. Narrow-spectrum antibiotics should be used whenever possible to prevent the development of resistance.

“The selection of an antimicrobial regimen for the treatment of symptomatic urinary infection is similar in all populations. There is a predictable decline in creatinine clearance with aging, but age by itself does not require changes in agent or dose.” [1]

First Line Agents

Recommended first line agents are as follows [2], [1], [4], [5]:

  • Nitrofurantoin 100 mg BID for 5 days
  • TMP/SMX 160/800 mg BID for 3 days
  • Fosfomycin 3 gm single dose
  • Pivmecillinam 400mg BID for 3-7 days. This agent has lower clinical efficacy (55-82%). This is unavailable in the United States.

Alternative Agents

In case of allergy or concurrent use of a medication with interactions, the following are alternatives, with treatment for 3-5 days:

  • Ciprofloxacin 250-500 mg BID
  • Levofloxacin 250-500 mg daily
  • Amoxicillin/clavulanic acid 500 mg TID or 875 mg BID
  • Cephalexin 500 mg QID
  • Cefuroxime 500 mg BID
  • Cefixime 400 mg daily
  • Cefpodoxime 100-200 mg BID

Cautions and Considerations

There are some important cautions and considerations for each of these medications.

Nitrofurantoin: This medication has high cure rates (93%), comparable to ciprofloxacin, Bactrim, and fosfomycin. Resistance rates to nitrofurantoin are very low (around 2% for E. coli) [6]. Nitrofurantoin is effective against most E. coli species, including extended spectrum beta-lactamase (ESBL)-producing E. coli and also vancomycin-resistant enterococci (VRE) [1]. In general it is tolerated very well, and allergy to nitrofurantoin is uncommon. It has minimal ecologic adverse effects (ie development of resistant strains) [5].

  • Caution 1. Resistance: In general there are very low resistance rates to nitrofurantoin. However, Enterobacteriaceae such as proteus may be resistant. If the patient has a history of UTI with gram negative bacteria resistant to nitrofurantoin, TMP/SMX (Bactrim) would be a better choice.
  • Caution 2. Pyelonephritis: Avoid if you are concerned about early pyelo, as nitrofurantoin does not sufficiently penetrate the renal tissue to treat pyelonephritis [4].
  • Caution 3. Renal Impairment: The classic teaching on nitrofurantoin was that it is ineffective at creatinine clearances or glomerular filtration rate (GFR) of <60mL/min because it does not concentrate in the urine sufficiently. Consensus guidelines from 2008 recommended against nitrofurantoin use if the GFR is <60mL/min [7]. An additional complication is that for older adults, calculations can over-estimate the GFR. However, some new evidence suggests that nitrofurantoin is effective even with a low GFR. One large retrospective study found nitrofurantoin was as effective in women with moderate renal impairment (GFR 30-50 mL/min) compared with trimethoprim for uncomplicated UTIs [8]. Another retrospective study compared patients with GFR>50 mL/min and http://cph.sagepub.com/content/142/5/248.short?rss=1&ssource=mfr, and a review of the evidence by one group concluded that there was limited data supporting the contraindication of nitrofurantoin for patients with GFR < 60, and state that currently available data supports its use in patients with GFR of > 40 mL/min [9]. More studies are needed before definite recommendations can be made.

TMP/SMX. This is a reasonable first line agent, and is widely used. However, resistance has become a problem in many areas.

  • Caution 1. Resistance: You should consult your hospital’s antibiogram. In one cohort of community-dwelling older women, 32% of E. coli isolated from patients with UTI were resistant to TMP/SMX.  Avoid if your resistance rates are greater than 20%, or if it has been used in that patient for a UTI in the last 3 months [4].
  • Caution 2. Allergy: Sulfa allergies are common. The moiety responsible for the allergic reaction is present in other sulfonamide antibiotics (such as sulfasalazine and sulfadiazine) and in anti-retrovirals (such as amprenavir and fosamprenavira). The chemical structures in other “sulfa” drugs such as furosemide, hydrochlorothiazide, glipizide, and others should not have true cross-reactivity [10].
  • Caution 3. Interaction with warfarin: TMP/SMX can increase the INR and increase the risk bleeding complications on patients on vitamin K antagonists.
  • Caution 4. Consider another medication in older patients with renal failure, or who are on NSAIDs or medications that could predispose them to renal failure or hyperkalemia.

Fosfomycin. This agent is less commonly used. It offers the simplicity of a single dose, avoiding the concerns of non-adherence. There is not as much data on the use of fosfomycin, although the studies that have been done showed clinical cure rates that were similar to other first line agents [4]. Resistance data is not as widely available as most labs do not test for fosfomycin resistance. However, it is effective against VRE, methicillin-resistant S. aureus (MRSA), and ESBL-producing gram-negative rods.

  • Caution 1. Pyelonephritis: Avoid if you are concerned about early pyelonephritis.
  • Caution 2. Fosfomycin may not be available in all outpatient pharmacies. If you plan to use it, give a dose in the ED.

Fluoroquinolones. Ciprofloxacin is a commonly used first line agent, and a 3 day course is probably as effective as 7 days [11]. However, resistance rates have become so high that it is now recommended ciprofloxacin be reserved for patients who cannot use other first line agents, who have more severe infections, or who have organisms resistant to other agents [4], [2]. Levofloxacin is also an effective agent, but provides broader coverage than is needed for most simple UTIs. It is best reserved for patients with complicated UTIs and pyelonephritis.

  • Caution 1. Resistance: Resistance in community dwelling older adults is around 17% for fluoroquinolones, and may be even higher in long-term care residents [2]. Consult your hospital’s antibiogram.
  • Caution 2. Interaction with warfarin: Levofloxacin can increase the effect of warfarin leading to higher INR and potential for bleeding complications.

Summary

  1. When treating an uncomplicated UTI, check for prior culture resistance patterns for the patient.
  2. Recommended first-line agents include TMP/SMX, nitrofurantoin, and fosfomycin.
  3. Nitrofurantoin has low resistance rates, high cure rates, and few medication interactions. More data is needed regarding its use in renal impairment (see post by Bryan Hayes, PharmD), but it should be effective for those with a GFR >60mL/min.
  4. Fluoroquinolones have high resistance rates and should be reserved for patients who cannot take one of the other agents, or who have more severe infections.
  5. Oral cephalosporins may serve as an alternative therapy in patients who use warfarin. TMP/SMX and levofloxacin can both increase the INR.

  Image credit

References

  1. L.E. Nicolle, "Urinary tract infections in the elderly.", Clinics in geriatric medicine, 2009. http://www.ncbi.nlm.nih.gov/pubmed/19765490
  2. T.A. Rowe, and M. Juthani-Mehta, "Diagnosis and management of urinary tract infection in older adults.", Infectious disease clinics of North America, 2013. http://www.ncbi.nlm.nih.gov/pubmed/24484576
  3. J.G. Ouslander, M. Schapira, J.F. Schnelle, and S. Fingold, "Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents.", Journal of the American Geriatrics Society, 1996. http://www.ncbi.nlm.nih.gov/pubmed/8636589
  4. K. Gupta, T.M. Hooton, K.G. Naber, B. Wullt, R. Colgan, L.G. Miller, G.J. Moran, L.E. Nicolle, R. Raz, A.J. Schaeffer, D.E. Soper, . , and . , "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.", Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21292654
  5. T.M. Hooton, "Clinical practice. Uncomplicated urinary tract infection.", The New England journal of medicine, 2012. http://www.ncbi.nlm.nih.gov/pubmed/22417256
  6. G.V. Sanchez, R.N. Master, J.A. Karlowsky, and J.M. Bordon, "In vitro antimicrobial resistance of urinary Escherichia coli isolates among U.S. outpatients from 2000 to 2010.", Antimicrobial agents and chemotherapy, 2012. http://www.ncbi.nlm.nih.gov/pubmed/22252813
  7. J.T. Hanlon, S.L. Aspinall, T.P. Semla, S.D. Weisbord, L.F. Fried, C.B. Good, M.J. Fine, R.A. Stone, M.J.V. Pugh, M.I. Rossi, and S.M. Handler, "Consensus guidelines for oral dosing of primarily renally cleared medications in older adults.", Journal of the American Geriatrics Society, 2008. http://www.ncbi.nlm.nih.gov/pubmed/19170784
  8. A.F.J. Geerts, W.L. Eppenga, R. Heerdink, H.J. Derijks, M.J.P. Wensing, T.C.G. Egberts, and P.A.G.M. De Smet, "Ineffectiveness and adverse events of nitrofurantoin in women with urinary tract infection and renal impairment in primary care.", European journal of clinical pharmacology, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23660771
  9. M. Oplinger, and C.O. Andrews, "Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence.", The Annals of pharmacotherapy, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23341159
  10. C.C. Brackett, H. Singh, and J.H. Block, "Likelihood and mechanisms of cross-allergenicity between sulfonamide antibiotics and other drugs containing a sulfonamide functional group.", Pharmacotherapy, 2004. http://www.ncbi.nlm.nih.gov/pubmed/15303450
  11. T. Vogel, R. Verreault, M. Gourdeau, M. Morin, L. Grenier-Gosselin, and L. Rochette, "Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial.", CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2004. http://www.ncbi.nlm.nih.gov/pubmed/14970093

Author information

Christina Shenvi, MD PhD
Christina Shenvi, MD PhD
Geriatric Emergency Medicine Fellow
University of North Carolina

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