Blood Transfusion in 2014

I had several discussions in ED regarding blood transfusion in anemic patients. My argument is that if patient does not have any acute symptoms (SOB, feeling faint, tachycardia, Cardiac ischemia, …), there is no need to emergently transfuse patients in ED. Our threshold to transfuse was 10/30 vs 9/28/ vs 8/26 long time ago and there was no definite number to stick to. In 2006, Journal of Trauma published a practice guideline: Guidelines for transfusion in the trauma patient. They recommended a threshold of Hb 7 to transfuse but non-surgeons doctors argued this with their specific patient population that they have. The argument was: trauma patients usually are young without morbidity or significant PMH, but medicine patients usually suffer from diseases and anemia can affect this threshold! When this study published in NEJM: Transfusion strategies for acute upper gastrointestinal bleeding. There was no argument that sick patient with UGIB could benefit from restrictive plan!

Now in JAMA: Health Care–Associated Infection After Red Blood Cell Transfusion A Systematic Review and Meta-analysis there is a systematic review with 18 studies that shows a restrictive plan for transfusion will help to reduce blood borne diseases. Do we still argue this?

Biphasic allergic reaction

We are usually observing patients in emergency department in length due to biphasic reaction. There are 2 articles published during last 6 months and they emphasized regarding of  how common is biphasic reaction and mortality of this reaction!

The first one published in annals of EM in Nov 2013 tiltled: “Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis“. Their objective was questionable rate of bipasic reaction and also prolong ED LOS. They Reviewed 2,819 patients, 496 anaphylactic and 2,323 allergic reactions. among these 185 patients returned at least 1 time to ED related to allergic complaints. among these 5 had significant biphasic reactions. 2 of anaphylaxis group(496)  happened in ED(16, 200 min), and 3 among allergic reaction(2323). none happened in ED. almost 6 % returned to ED with related “allergic” symptoms. Their conclusion is biphasic reaction and fatality are rare and it is not necessary in simple, uncomplicated cases to observe patient in length in ED.

Link to article

The Second study was published in Allergy Apr. 2014. The objectives are  the rate of biphasic – andit’s importance and  anaphylactic reactions, transfers to ICU, and deaths within 10 days of presentation to the ED. Study Period from 2001 to 2013.  From 1334, 532 allergic reaction and 495 patients had anaphylactic reaction. In 227 (44.8%) the LOS was ≥8 h.  507 uniphasic and 25 (4.5%) biphasic. 12 (2.3%) were clinically important, including 2 (0.36%) that occurred during hospital stay, one of whom (0.19%) was transferred to ICU for shock. No risk factors for biphasic reactions could be found. No death within 10 days. Their conclusion is “to consider discharging patients after complete resolution of an anaphylactic reaction and to dispense with prolonged monitoring”.

 Link to article

 

Cardiac Risk factors, How important are they?

This is an old study by Annals of EM, The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes in the Emergency Department Setting, Feb 2007. Of 10,806 eligible patients, 871 (8.1%) had acute coronary syndromes. Cardiac risk factors was identified: diabetes, hypertension, smoking, hypercholesterolemia, and family history of coronary artery disease. Interestingly in patients less than 40 years old without cardiac risk factors had a negative likelihood ratio of 0.17 and having 4 or more risk factors had a positive likelihood ratio of 7.39. In patients between 40 and 65 years of age, having no risk factors had a negative likelihood ratio of 0.53, and having 4 or more risk factors had a positive likelihood ratio of 2.13. In patients older than 65 years, having no risk factors had a negative likelihood ratio of 0.96 , and having 4 or more risk factors had a positive  likelihood ratio of 1.09.  The conclusion was:”Cardiac risk factor burden has limited clinical value in diagnosing acute coronary syndromes in the ED setting, especially in patients older than 40 years”.

Link to article

Still MAP of 65 Works!

NEJM published a study regarding appropriate MAP among patients with septic shock. Originally MAP of 65 was a target but the Surviving Sepsis Campaign guideline was recommending patients with HTN, may have benefit for higher MAP. In this study 776 patients with septic shock during resuscitation targeted MAP of 65- 70 mm Hg vs 80-85 mm Hg.  No significant mortality was found between these groups at 28 days and 90 days. They found higher rate of new atrial fibrillation among higher MAP group(80-85). Conclusions is “Targeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days”.

 

Link to article:

EGDT or ProCESS , That is the question!

NEJM published The ProCESS study. Basically, this study aimed to challenge EGDT by Manny Rivers in 2001, a very prestigious and novel approach to septic patient in ED. The EGDT was ED based approach. although some of the components were very difficult to acheived in ED such as Scvo2. The EGDT study showed 16% reduction in mortality, but Rivers faced lots of questions including feasibility of this approach in ED, and necessity of blood transfusion and etc… The whole concept was to have better oxygen delivery to tissue!
The ProCESS study published in NEJM this month enrolled 1351 patients from  March 2008 through May 2013  lead by the University of Pittsburgh. Patients were assigned to one of the 3 groups:
1. protocol-based EGDT: mainly Rivers protocol
2. protocol-based standard therapy: less aggressive approach: blood transfusion at Hb 7.5 and no mandatory central line access, etc
3. usual care: community based approach, they let providers take care of patient without any prompt or protocol
the study conclusion is :
They found no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician’s judgment.
******
The Rivers concept that we should remember and nobody can challenge is :
early resuscitation
early recognition of patient’s pathology
early oxygenation
Volume(IVF, or Blood transfusion)
early treatment(Abx)
Hospital Admission
and this is all we do in ED: Cath attack, Brain attack, Trauma activation, all have good outcomes because they are EGDT. We all know if you see a patient and order early cardiac monitor, o2 , IV … you will have a better understanding of patient, I believe we should do EGDT as our approach to every single patient regardless of  disease process and symptom/sign.  The concept of EGDT should stay with us regardless being true in sepsis or not!
Don’t forget to practice EARLY and GOAL DIRECTED in EM!

ACEP Practice Guideline on Procedural Sedation

ACEP published Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department in Feb 2014. as usual critical questions and very useful answers. Let’s review them:

1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

Level B recommendations. Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?

Level B recommendations. Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.

*Capnography includes all forms of quantitative exhaled carbon dioxide analysis.

3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?

Level C recommendations. During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition  to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?

Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.

Level B recommendations. Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.

Level C recommendations. Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

Link to Policy on ACEP website