Spontaneous Bacterial Peritonitis

Definition: Acute infection of the ascitic fluid in a patient with liver disease without another source of infection

Epidemiology: (Runyon 1988, Runyon 1988, Borzio 2001)

  • Incidence
    • 10-25% risk of at least one episode per year
    • 20% risk in those with ascites admitted to the hospital
  • Historically, mortality ~ 50%

Pathophysiology:

  • Not completely understood
  • Increased portal systemic hypertension
    • Causes mucosal edema of the bowel wall
    • Increases transmural migration of enteric organisms into the ascitic fluid
  • Impaired phagocytic function in the liver
  • Impaired immunologic activity in ascitic fluid

Presentation:

  • Classic triad: fever, abdominal pain and increasing ascites. Presence of all three components uncommon
  • Symptoms
    • Fever or chills
    • Abdominal pain
    • Abdominal swelling
    • Fatigue
    • Malaise
  • Signs
    • Abdominal tenderness variable
      • Typically diffuse
      • Can be mild without peritoneal signs
      • Can be severe with rebound and/or guarding
    • Abdominal distension
    • Altered mental status (from hepatic encephalopathy)

Diagnostics:

  • Obtaining an ascitic fluid sample is critical in making the diagnosis
  • Serum blood tests (i.e. WBC, CRP, ESR) are not helpful in making this diagnosis
  • Due to variable presentations and considerable mortality associated with SBP, consideration should be made to perform paracentesis on ALL patients with ascitic fluid who are being admitted (Gaetano 2016)
  • Diagnostic paracentesis (EM: RAP HD)
  • Paracentesis (DrER.tv)

    Ascitic fluid assays

    • Cell count
      • Look for WBC > 250-500 cells/mm3 or neutrophil count > 250 cells/mm3
      • Peritoneal dialysis patients: neutrophil count > 100 cells/mm
    • pH < 7.34 more common in SBP (Wong 2008)
    • Ascitic fluid gram stain (rarely positive) and culture
  • If patient has fever (temp > 100oF) or abdominal pain/tenderness, empiric antibiotics should be given even if neutrophil count < 250 cells/mm3

Management:

  • Antibiotics
    • Most common bacterial causes: E. Coli, S. Pneumoniae, Enterococci
    • 3rd Generation Cephalosporin covers vast majority of cases
      • Ceftriaxone 25 mg/kg up to 1 gm daily
      • Cefotaxime 25 mg/kg up to 1 gm Q8
    • Alternate antibiotic choices
      • Ciprofloxacin 400mg IV BID
      • Levofloxacin 750mg IV daily
      • Piperacillin/Tazobactam 4.5g IV TID
      • Ertapenem 1g IV qD
      • Imipenem/Cilastatin 500mg IV QID
  • Albumin Infusion (Runyon 2012)
    • Recommended by American Association for the Study of Liver Disease (AASLD) in specific subgroups with SBP
      • Presence of any of the following should prompt albumin administration
      • Serum creatinine > 1 mg/dL
      • Blood urea nitrogen (BUN) > 30 mg/dL
      • Total Bilirubin > 4 mg/dL
    • Impact of albumin infusion (Sort 1999)
      • 25% reduction in renal failure
      • 20% reducing n mortality
    • Dose
      • 1.5 grams/kg within 6 hours
      • 1.0 grams/kg on day 3 of treatment
  • Patients with a single episode of SBP should be considered for antibiotic prophylaxis (with norfloxacin, ciprofloxacin or TMP/SMX) (Runyon 2012)

Approach to the Diagnosis and Treatment of SBP (University of Washington)

Take Home Points:

  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)

For More on this Topic Checkout:

References:

  1. Runyon BA et al. Ascitic fluid analysis in malignancy‐related ascites. Hepatology 1988; 8(5):1104-1109. PMID: 3417231
  2. Runyon BA. Spontaneous bacterial peritonitis: An explosion of information. Hepatology 1988; 8: 171–175. PMID: 3338704
  3. Borzio M et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis 2001; 33(1): 41-48. PMID: 11303974
  4. Gaetano et al. The benefit of paracentesis on hospitalized adults with cirrhosis and ascites. Journal of Gastroenterology and Hepatology 2016. PMID: 26642977
  5. Wong CL et al. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 2008; 299(10):1166-78. PMID: 18334692
  6. Runyon BA. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012. AASLD Practice Guideline. Link
  7. Sort P et al. Intravenous albumin in patients with cirrhosis and spontaneous bacterial peritonitis. NEJM 1999; 341: 1773-4. PMID: 10432325

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)

The post Spontaneous Bacterial Peritonitis appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

REBEL Cast Episode 42: Research From the Past Year – In the Pipeline

Welcome back to Episode 42 of REBEL Cast. In this episode, we will be discussing some studies from the past year that had some interesting results and a couple of papers that are potentially going to change our practice in the near future (In the Pipeline). Again, this 3 part series will be dedicated to discussing current literature and how it can be applied to your clinical practice.

Episode 42 – Research From the Past Year – In the Pipeline

Click here for Direct Download of Podcast

Study #1:

Caputo N et al. EmergeNcy Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med 2017 PMID: 28791755

Blog Post HERE: The ENDAO Trial – Is Apneic Oxygenation a Futile Intervention in ED RSI?

  • RCT in ED 200 pts
  • Mean Lowest SpO2:
    • ApOx: 92%
    • No ApOx: 93%
  • Both groups preoxygenated for 13 minutes
  • Over 70% of patients were successfully intubated by 60 seconds, 80% by 80 seconds, 90% by 100seconds, and 100% by 195 seconds
  • Bottom LIne: In patients who receive proper pre-oxygenation (3min with flush 100% O2), apneic oxygenation may be a superfluous intervention, however it is important to remember that AO is not a complicated procedure, not expensive, and has not been shown to be  harmful.  Additionally, the absence of benefit here doesn’t mean there is no group who won’t benefit (i.e. prolonged apnea times and crash intubations) but, it is nearly impossible to make accurate prospective predictions as to which patients will benefit the most.

Study #2:

Marik P et al. Hydrocortisone, vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017. PMID: 27940189

Blog Post HERE: The Marik Protocol – Have We Found a “Cure” for Severe Sepsis and Septic Shock

  • Retrospective Before and After Study of 94 pts
  • No Vitamin C Protocol vs Vitamin C Protocol
    • Duration of Vasopressors 3hr vs 54.9hr (<1d vs 2d)
    • Hospital Mortality: 40.4% vs 8.5% (NNT = 3)
  • The exact dosing strategy for Vitamin C is unknown, as it is not that well studied. The authors conclude that up to 6g daily should be enough without running the risk of conversion to oxalate and potentially causing worsening renal impairment from oxalate deposition.
  • In this trial the exact dosing was:
    • Vitamin C 1.5g q6hrs x4days
    • IV hydrocortisone 50mg q6hr x7d or ICU DC + a 3 day taper
    • IV thiamine 200mg q12hr x4d or ICU DC
  • Bottom Line: Although the results of this study are very promising, it is important to remember that this is only a hypothesis generating study.  We still need an external validation before implementation (How many other treatments in sepsis have been touted as a “cure” and not panned out in subsequent studies?).

Study #3:

Aycock RD et al. Acute Kidney Injury After Computed Tomography. A Meta-Analysis. Ann Emerg Med 2017. PMID: 28811122

Blog Post HERE: Is Contrast Induced Nephropathy (CIN) Really Not a Thing?

  • Systematic Review and Meta-Analysis
  • 28 Studies with over 107,000 patients (No RCTs)
  • IV Contrast vs no IV Contrast Enhanced CTs:
    • Not Associated with more AKI (Primary Outcome 26 studies): OR 0.94 (95% CI 0.83 – 1.07)
    • Not Associated with more Renal Replacement Therapy (13 studies): OR 0.83 (95%CI 0.59 – 1.16)
    • Not Associated with Increased Mortality (9 studies): OR 1.0 (95% CI 0.73 – 1.36)
  • Early contrast agents used mono-iodinated rings and ionic monomers making Hyperosmolar solutions (1500mOsm) relative to serum are severe irritants and more likely to cause vasodilation, increased capillary permeability, and mast cell degranualation
  • Newer lower and iso osmolar (290 – 800mOsm) contrast agents use di- and tri-iodinated rings with non-ionic monomer…90 – 95% of iodinated contrast media used in US
    • High: 1500mOsm
    • Low: 320 – 800mOsm
    • Iso: 290mOsm
  • Many studies fail to account for the patients’ other risk factors for development of acute kidney injury, including sepsis, dehydration, end-organ dysfunction, or administration of nephrotoxic medications
  • Bottom Line: While a prospective, multi center RCT would put this question to rest, it’s unlikely to be feasible to perform. Based on the best available evidence, use of IV low- and iso-osmolar contrast media does not appear to be associated with increased risk of AKI, need for renal replacement therapy, or mortality.

Study #4:

Khanna A et al. Angiotensin II for the Treatment of Vasodilatory Shock. ATHOS-3. NEJM 2017 PMID: 28528561

  • RCT of 404 patients angiotensin II vs placebo in patients requiring high dose norepi >0.2mcg/kg/min or equivalent vasopressor for ≥6hrs but ≤48hrs
  • Angiotensin II has various effects from potentiating sympathetic activity, direct vasoconstriction, and fluid retention directly and indirectly (via release of aldosterone and vasopressin/antidiuretic hormone).
  • Response in MAP: A response was defined as an increase in MAP of at least 10 mm Hg from baseline or a MAP of at least 75 mm Hg without an increase in baseline vasopressor infusions.
  • Response in MAP:
  • Angiotensin II: 69.9%
  • No Angiotensin II: 23.4%
  • NNT = 2
  • Study powered to show improvement in blood pressure, a clinically important parameter, but underpowered to demonstrate a mortality difference, a patient oriented outcome
  • Bottom Line: Angiotensin II added to high dose norepinephrine infusion (>0.2mcg/kg/min) is associated with an improvement in blood pressure at hour 3 of therapy vs. placebo without an increase in adverse effects, however more studies are still required to determine patient oriented outcomes.

Well that’s it for part 3 of this 3 part series.  Hope this review was helpful and be sure to leave us your comments on any of these studies. Two more things before we let the listeners go…

First, REBEL EM is proud to announce our first ever clinical conference, Rebellion in EM, happening May 11th – 13th, 2018 in San Antonio, TX.  Just go to rebellioninem.com to register.

Finally, as always, be sure to follow us on Facebook and Google+ REBEL EM, two words, no periods.  Until next time REBEL EMers.

References:

  1. Caputo N et al. EmergeNcy Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med 2017 PMID: 28791755
  2. Marik P et al. Hydrocortisone, vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017. PMID: 27940189
  3. Aycock RD et al. Acute Kidney Injury After Computed Tomography. A Meta-Analysis. Ann Emerg Med 2017. PMID: 28811122
  4. Khanna A et al. Angiotensin II for the Treatment of Vasodilatory Shock. ATHOS-3. NEJM 2017 PMID: 28528561

The post REBEL Cast Episode 42: Research From the Past Year – In the Pipeline appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

Clinical Pearls from ACEP 2017 – Washington D.C.

This year ACEP 2017 took place in Washington D.C. from Oct. 29th – Nov 1st, 2017.   There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP17 hashtag.  I was fortunate enough to attend this amazing conference and approached by several attendees if I would put together a list of my favorite pearls from this conference.  I decided to put a top 10 list together, in no particular order.

Pearl #1: The Diagnostic Performance of Computer Programs for Interpretation of of ECGs[1]

  • What They Did: Comparison of 9 ECG computer programs vs 8 cardiologists interpreting 1220 clinically validated cases of various cardiac disorders
  • Control patients = 382
  • LVH = 183
  • RVH = 55
  • Anterior MI = 170
  • Inferior MI = 273
  • Median Correct Diagnosis:
    • Computer Programs: 91.3%
    • Cardiologists 96.0%
    • p < 0.01
  • Median Sensitivity to Diagnose Anterior MI
    • Computer Programs: 77.1%
    • Cardiologists: 84.9%
    • p < 0.01
  • Median Sensitivity to Diagnose Inferior MI:
    • Computer Programs: 58.8%
    • Cardiologists 71.7%
    • p < 0.001
  • The median total accuracy level (percentage of correct classifications was 6.6% lower for computer programs than cardiologists (69.7% vs 76.3%)
  • Study Bottom Line: Don’t rely on the computer for ECG interpretations

Pearl #2: Hyperkalemia is the “Syphilisof ECGs [2]

  • What They Did: Collected 188 ECGs of patients with severe hyperkalemia (K+ ≥6.5mEq/L)
  • Adverse events occurred within 6 hours in 28 patients (15%)
    • Symptomatic Bradycardia in 22 patients (12%)
    • Death in 4 patients (2%)
    • Ventricular Tachycardia in 2 patients (1%)
    • CPR in 2 patients (1%)
  • All adverse events occurred prior to treatment with calcium
  • Most Common ECG Findings Predicting Adverse Outcomes:
    • QRS prolongation 79%
    • Bradycardia (HR <50 bpm) 61%
    • PR Prolongation 50%
    • Junctional Rhythm 39%
    • Peaked T Waves 25%
  • We have written about this before on REBEL EM: ECG Changes of Hyperkalemia
  • Study Bottom Line: When ACLS is not working, think tox or hyperK+ (i.e. In a code situation, just give Calcium prior to K+ level as there is really no downside to doing this)

Pearl #3: Tidal Volume on the Ventilator is Based off IDEAL BODY WEIGHT not Actual Body Weight

  • Lung Size for a 250lb and 100lb patient of the same height are essentially the same

Pearl #4: If you Have a Critical Patient and Can’t Get IV Access Consider These Options [3] [4]

  • What They Did: 16 Cadavers underwent a 5 minute bolus infusion of fluid via three IO access sites:
    • Flow Rates:
      • Sternum: 93.7 mL/min
      • Proximal Humerus: 57.1mL/min
      • Proximal Tibia: 30.7 mL/min
    • Sternum access requires special IO needle not always available at institutions and could affect CPR quality
    • Tibial Access had the greatest number of insertion difficulties
  • What They Did: Multicenter prospective observational trial to evaluate the efficacy and safety of the Easy IJ in 74 patients
  • Study Bottom Line: If you are having difficulty getting IV access in your critically ill patient, consider, IO access Proximal Humerus > Proximal Tibia or the Easy IJ

Pearl #5: Nitroglycerin NOT Furosemide Should Be First-Line in Treatment of CHF and Pulmonary Edema

  • The goals of treatment in cardiogenic pulmonary edema
  1. Decrease Preload
  2. Decrease Afterload
  3. Improve LV Function
  • Initial treatment should therefore focus on fluid redistribution not fluid removal
  • Morphine associated with increased intubation, Increased ICU admission, and Increased mortality; No role in treatment of cardiogenic pulmonary edema [5]
  • Diuretics: Due to increased afterload, effects are often delayed 30 – 120 minutes; Not effective in anuric ESRD patients; May also decrease CO during first 90 minutes [6]
  • Nitroglycerin: Rapid, reliable preload reduction and effective afterload reduction at higher doses, so be aggressive 100 – 400mcg/min [7]
  • NIPPV; Decreases preload and afterload which help increase CO
  • More than 50% of patients with cardiogenic pulmonary edema are euvolemic [8]
  • Summary of Treatment Options in Cardiogenic Pulmonary Edema:
  1. NIVPPV – First line treatment
  2. Nitroglycerin – First line agent
  3. ACE-Inhibitors – Second line agent
  4. Furosemide – Third Line Agent

Pearl #6: Remember the Rule of 15’s for Pre-Oxygenation Prior to RSI to Prevent Oxygen Desaturation

  • Back Up Head Elevated (BUHE) Intubation [9]:
    • 528 Intubations
    • Primary Outcome: Composite of Any Intubation Related Complication (Difficult Intubation ≥3 Attemps or >10 min, Hypoxemia <90% O2 Sat, Esophageal Intubation, or Esophageal Aspiration)
      • Standard Supine Intubation: 22.6%
      • BUHE Intubation 9.3%
  • Flush Rate O2 for Pre-Oxygenation [10]:
    • Crossover trial with healthy volunteers with:
      • NRB at 15L/min (NRB-15)
      • NRB with Flush Rate (>40L/min) O2 (NRB-Flush)
      • BVM Device with O2 at 15L/min (BVM-15)
      • Simple Mask with Flush Rate (>40L/min) O2 (SM-Flush)
    • Forced Expiratory O2 in a single Exhaled Breath (FeO2) After 3 Min Pre-Oxygenation:
      • NRB-15: 54%
      • NRB-Flush: 86%
      • BVM-15: 77%
      • SM-Flush: 72%
  • Apneic Oxygenation RCT in the ED [11]:
    • Single Institution RCT of 200 patients randomized to Apneic Oxygenation vs No Apneic Oxygenation
    • Lowest Mean O2 Saturation:
      • Apneic Oxygenation: 92%
      • Usual Care: 93%
    • Caveats: 70% of patients intubated by 60 seconds, 80% by 80 seconds, 90% by 100 seconds, and 100% by 195 seconds
    • All patients pre-oxygenated for ≥ 3minutes
  • In patients with shunt physiology (Pneumonia, Pulmonary Edema, PE), remember that oxygenation will not help as much as PEEP (Recruit Atelectatic Alveoli)
  • For all causes of hypoxia NC>15LPM + BVM 15LPM _ PEEP Valve 15cmH20 = Best PreOx, ApOx, and ReOx currently available
  • Bottom Line of Studies:

Pearl #7: Radiologists are NOT “All-Seeing” [12]

  • “The Invisible Gorilla Strikes Again”
  • 24 radiologists had up to 3 minutes to freely scroll through lung CTs searching for nodules
  • A Small Gorilla was also superimposed on the CTs as an experiment of inattentional bias
  • 20/24 (83%) radiologists failed to see the gorilla
  • Study Bottom Line: ALWAYS look at all radiology images that you order and not just the radiology read

Pearl #8: NPO Status in Pediatric Patients Prior to Sedation/Anesthesia Outside the Operating Room [13]

  • What They Did: Pediatric Sedation Research Consortium evaluated >139,000 procedural sedation/anesthesia encounters from 42 institutions
  • Evaluated Aspiration Episodes and Composite Major Adverse Events (Aspiration, Death, Cardiac Arrest, Unplanned Hospital Admission) with respect to NPO status
  • Aspiration:
    • NPO = 8/82,546 (0.01%)
    • Non-NPO = 2/25,401 (0.008%)
  • Composite Major Adverse Events:
    • NPO = 46/82,546 (0.06%)
    • Non-NPO = 15/25,401 (0.06%)
  • 0 Deaths
  • Study Bottom Line: There is no association between NPO status and aspiration or composite major adverse events in sedation procedures outside the OR

Pearl #9: Regional Nerve Blocks for Hip Fractures [14]

  • What They Did: Multicenter RCT of 161 geriatric patients with hip fractures with US Guided Single Injection Femoral Nerve Block and then randomized to:
    • Fascia Iliaca Block (FIB) by Anesthesiology within 24 hours
    • Conventional Analgesics
  • Fascia Iliaca Block Superior to Conventional Analgesics
    • Improved Pain Control at 2 Hours
    • Pain Scores at Rest, With Transfers out of Bed, and With Walking on POD 3 Improved
    • At 6 Weeks Improved Walking and Stair Climbing Ability
    • Required 33 – 40% Fewer Parenteral Morphine Sulfate Equivalents
  • Study Bottom Line: Femoral nerve blocks result in superior outcomes in geriatric patients with hip fractures compared to parenteral pain medications

Pearl #10: Some Fun with Number Needed to Treat

  • ASA in STEMI:
    • NNT for Mortality = 42
    • NNH for Minor Bleeding = 167
  • NIPPV for COPD Exacerbation:
    • NNT for Mortality = 8
    • NNT for Avoiding Intubation = 5
  • Abx for COPD Exacerbation:
    • NNT for Mortality = 8
    • NNT for Preventing Tx Failure = 3
  • NIPPV for Acute Pulmonary Edema
    • NNT for Mortality = 13
    • NNT for Preventing Intubation = 8
  • Heparin for ACS
    • NNT to Prevent Nonfatal Heart Attack = 33
    • NNH for Major Bleeding = 25

References:

  1. Willems JL et al. The Diagnostic Performance of Computer Programs for the Interpretation of Electrocardiograms. NEJM 1991. PMID: 1834940
  2. Durfey N et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term adverse Events? West J Emerg Med 2017. PMID: 28874951
  3. Pasley J et al. Intraosseous Infusion Rates Under High Pressure: A Cadaveric Comparison of Anatomic Sites. J Trauma Acute Care Surg 2015. PMID: 25757113
  4. Moayedi S et al. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. JEM 2016. PMID: 27658558
  5. Peacock WF et al. Morphine and Outcomes in Acute Decompensated Heart Failure: An ADHERE Analysis. Emerg Med J 2008. PMID: 18356349
  6. Ikram et al. Haemodynamic and Hormone Responses to Acute and Chronic Furosemide Therapy in congestive Heart Failure. Clin Sci 1980. PMID: 7002435
  7. Wilson SS et al. Use of Nitroglycerin by Bolus Prevents Intensive Care Unit Admission in Patients with Acute Hypertensive Heart Failure. Am J Emerg Med 2017. PMID: 27825693
  8. Chaudry SI et al. Patterns of Weight Change Preceding Hospitalization for Heart Failure. Circulation 2007. PMID: 17846286
  9. Khandelwal N et al. Head-Eleavted Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016. PMID: 26866753
  10. Driver BE et al. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med 2017. PMID: 27522310
  11. Caputo N et al. EmergeNcy Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med 2017. PMID: 28791755
  12. Drew T et al. “The Invisible Gorilla Strikes Again: Sustained Inattentional Blindness in Expert Observers.” Psychol Sci 2014. PMCID: PMC3964612
  13. Beach ML et al. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Ouside the Operating Room: A Report of the Pediatric Sedation Consortium. Anesthesiology 2016. PMID: 26551974
  14. Morrison RS et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc 2016. PMID: 27787895

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

The post Clinical Pearls from ACEP 2017 – Washington D.C. appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.