JC. ROTEM for ED coagulopathy detection. St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

Coagulopathy is well known to be a significant issue in the ED. There is increasing awareness that the early awareness, detection and management of coagulation problems is important for ED management, but it’s tricky. Laboratory based tests may not tell us what we need to know about the effectiveness of blood clotting and as anyone who works in the ED knows, the results may not be back for some considerable time.

Karim Brohi spoke at SMACCGold on the subject of coagulation in trauma and those talks will really be worth a relisten when they come out later in the year. Real gold information for us all to learn from.

teg_1

So, interest in the management of coagulopathy is at the forefront of trauma resusucitation and with this there is an increasing interest in thromboelastography and rotational thromboelastometry, techniques that looks at the visco-elastic properties of whole blood as it clots. There is a nice summary of this on the Life in the fast line site which focuses on the TEG system (there is also ROTEM), but it’s a great review of the principles involved. You can also look a the practical haemostasis blog here which has a nice explanation of both.

It’s not all positive though. A Cochrane review from back in 2011 concluded that TEG/ROTEM does not improve morbidity or mortality which is interesting. Looking on the main Cochrane site it looks as though this is up for review again soon, but with a focus on trauma patients only.

Anyway, a number of trauma centres and EDs are beginning to use these techniques in the resus room. Last year I chose a paper on the subject by Davenport et al.  for the recent top 10 papers in trauma talk for the UK trauma conference as I believe this is an area where we may significantly influence patient treatment in the future. In that paper Davenport et al showed that ROTEM could identify coagulopathy in the resus room for trauma patients, predicting massive transfusion at an early stage of patient care. Click on the abstract below for a #FOAMed version of the paper, it’s worth a read.

Coagulopathy identification copy

That was then though, what about the now and what about non-trauma patients?

The European Journal of Emergency Medicine has just published a trial from Edinburgh looking at the use of ROTEM for the identification of coagulopathy in the ED amongst a mixed population.

 

Reed et al looked at 40 patients with mixed pathologies in an urban Scottish ED. They looked at clot firmness at 5 and 10 minutes using ROTEM predicts maximal clot firmness. Patients were all comers with hypovolaemic shock as opposed to the trauma only patients that we have seen in previous studies.

ROTEM

I was interested in this study as ROTEM is a technology that I would like to introduce to Virchester, and I believe that we will be getting one soon to guide management in the resus room. One argument to support the purchase of such a device is to provide information on a broader application than just trauma as major trauma patients are just one subset of a wider group of hypovolaemic, coagulopathic patients that we see in the ED. So, I was very interested to hear more about the practicalities and ease of use in EM. In that regard the experience in Edinburgh is a bit disappointing in that only 40 of 386 eligible patients were recruited, largely due to logistical problems with device operators. This seriously compromises the study as such selective and non-consecutive selection will usually lead to significant bias in the findings.

Of the 40 patients included there was good correlation of clot strength at 10 minutes with final clot strength and that’s useful to know, but correlation is not always the best way to analyse this data. When comparing two continuous measures we are arguably as interested in the number of outliers as much as overall correlation. Correlation simply means that as one value rises then so does the other, and if we are comparing two tests of coagulation then it is highly likely that they will correlate. As a clinician we are more interested in whether they agree, which is an important difference. A different approach to measuring agreement and in particular to detect outliers (results where there are significant discrepancies) is a Bland Altman plot. This gives a graphical representation of ‘how different’ the results between test are and also helps show whether discrepancies occur at all values or whether there is variation between agreement at high or low values (very important in the resus room where values are often at the extreme).

Wikipedia on Bland Altman

Lancet article on statistical methods for assessing agreement

In this study correlation is shown to be good, and a plot of values suggests that agreement is also good, but I think it’s always good to stop and think when you see correlation used as a measure of agreement for diagnostic tests. In many cases of continuous variable analysis (such as in this paper from EMA on blood gas agreement) Bland Altman is clearly a helpful way of demonstrating agreement across a range of values.

Bland Altman Plot

Bland Altman Plot

In summary this paper presents an interesting insight into the possibilities of using TEG or ROTEM in the management of a variety of patients in the resus room and whilst it is not the final word on the matter it does present some interesting findings that we need to consider here in Virchester. 40 patients can’t really tell us much about the test beyond a proof of concept and in that regard it is a useful piece of work.

I am still left with questions though and I wonder if you can help.

  1. I’d love to hear more from colleagues who are already using ROTEM and TEG in the resus room.
  2. I’d especially like to hear from anyone with experience of resus room TEG/ROTEM in non-trauma patients
  3. I’d like to see more research published on non-trauma patients in the resus room.
  4. I’d like to get my hands on a machine PDQ and hear about your experiences of the practical challenges of using it in the acute setting.

 

Lastly, if you like the blog then please subscribe to email updates (up on the right side of this screen where it says ‘follow us’ for details) and also have a look at the facebook page which we set up fairly recently. All comments and feedback welcome.

 

vb

 

S

 

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#SMACCGold Reflections. @docib joins @St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

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@docib on the left knows where to look….

A few days ago I returned home to the UK from Australia after a brief sojorn in Hong Kong and it’s time to think back and consider what SMACCGold meant to me and to ask myself just why it felt so different. Rather surprisingly, perhaps, the person who best summed SMACC Gold up in my mind wasn’t one of the high profile speakers, it wasn’t even another clinician, but one of the waiting staff in the conference venue.

What are you all?” she asked me

What do you mean?” asked I

“Well, we have all sorts of conferences here: Real Estate agents; Pharmaceutical companies; big businesses, but you all seem different. You are all so kind”

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@docib speaking on Chronic Pain

To me, this encapsulated perfectly what this conference was all about and that an “outsider” could spot this spoke volumes. The blogosphere has been overwhelmed, unsurprisingly, by articles extolling just how amazing this event was, which to a non attendee may seem like unnecessary hyperbole. This reaction, I believe, wasn’t because of the high quality of the presentations or the flamboyance of the opening ceremony, but because it felt like you were in a room full of compassionate, passionate, caring, like minded friends. It was an environment where adrenalized procedures were discussed, but the most memorable moments were spent talking about the most difficult issues we face and when personal stories were interwoven with education. In amongst the bravado and humour speakers weren’t afraid to give a little of themselves and this instilled genuine feeling of warmth and friendship throughout the auditorium. The conferences badges worn by all, stated only the wearer’s name, with no mention of grade, speciality or even profession. A chance conversation in the queue for coffee could be had with a paramedic student or a professor of emergency medicine and each was equally valuable and enjoyable, giving different insights into the strange world of critical care that we all inhabit.

As I read through the numerous blogs and twitter comments after the conference I am struck by a feeling of sadness that I didn’t get the opportunity to meet more of the delegates, but reassured that these relationships can grow over the next year leading up to SMACCUS in Chicago. Many who don’t use social media scoff at those who do, believing it to be superficial and an escape from reality, but it turns out, that in my opinion, the opposite is true. When meeting, in person, some of those whose comments I had read online the usual barriers were immediately broken down, allowing more meaningful friendships to develop in a shorter time. The use of Twitter also allowed real time audience interaction with speakers making them seem less distant and more accessible. This wasn’t didactic learning, but a conversation between colleagues who care.

So, what will I take back to work in the ED as I attempt re-entry into society? Perhaps that we will all always have a lot to learn, but that by treating our colleagues as friends and patients as if they were family our ability to care will always be greater. It’s not what we know that is important, but who we are.

Iain Beardsell

@docib

 

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#SMACCGold Reflections. @docib joins @St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

1922178_808054189222662_2120221078_n

@docib on the left knows where to look….

A few days ago I returned home to the UK from Australia after a brief sojorn in Hong Kong and it’s time to think back and consider what SMACCGold meant to me and to ask myself just why it felt so different. Rather surprisingly, perhaps, the person who best summed SMACC Gold up in my mind wasn’t one of the high profile speakers, it wasn’t even another clinician, but one of the waiting staff in the conference venue.

What are you all?” she asked me

What do you mean?” asked I

“Well, we have all sorts of conferences here: Real Estate agents; Pharmaceutical companies; big businesses, but you all seem different. You are all so kind”

1836878_808053572556057_570138417_o

@docib speaking on Chronic Pain

To me, this encapsulated perfectly what this conference was all about and that an “outsider” could spot this spoke volumes. The blogosphere has been overwhelmed, unsurprisingly, by articles extolling just how amazing this event was, which to a non attendee may seem like unnecessary hyperbole. This reaction, I believe, wasn’t because of the high quality of the presentations or the flamboyance of the opening ceremony, but because it felt like you were in a room full of compassionate, passionate, caring, like minded friends. It was an environment where adrenalized procedures were discussed, but the most memorable moments were spent talking about the most difficult issues we face and when personal stories were interwoven with education. In amongst the bravado and humour speakers weren’t afraid to give a little of themselves and this instilled genuine feeling of warmth and friendship throughout the auditorium. The conferences badges worn by all, stated only the wearer’s name, with no mention of grade, speciality or even profession. A chance conversation in the queue for coffee could be had with a paramedic student or a professor of emergency medicine and each was equally valuable and enjoyable, giving different insights into the strange world of critical care that we all inhabit.

As I read through the numerous blogs and twitter comments after the conference I am struck by a feeling of sadness that I didn’t get the opportunity to meet more of the delegates, but reassured that these relationships can grow over the next year leading up to SMACCUS in Chicago. Many who don’t use social media scoff at those who do, believing it to be superficial and an escape from reality, but it turns out, that in my opinion, the opposite is true. When meeting, in person, some of those whose comments I had read online the usual barriers were immediately broken down, allowing more meaningful friendships to develop in a shorter time. The use of Twitter also allowed real time audience interaction with speakers making them seem less distant and more accessible. This wasn’t didactic learning, but a conversation between colleagues who care.

So, what will I take back to work in the ED as I attempt re-entry into society? Perhaps that we will all always have a lot to learn, but that by treating our colleagues as friends and patients as if they were family our ability to care will always be greater. It’s not what we know that is important, but who we are.

Iain Beardsell

@docib

 

The post #SMACCGold Reflections. @docib joins @St.Emlyn’s appeared first on St Emlyns.

JC: Rapid update on the resus pearls of 2013. St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

Two papers on the prepublication list at the Resuscitation Journal. The first is open access (#FOAMed), and both are worth a read. There are some great resus pearls in here.

Paper 1 covers highlights in epidemiology, cardiac arrest prevention, BLS, education, defibrillation, pregnancy, trauma, drowning and avalanche (!).

Screenshot 2014-03-29 11.37.54

Paper 2 covers highlights in ALS, post resus care, prognostication and cardiac arrest centres.

Screenshot 2014-03-29 11.37.09

There’s a lot in these papers so I’m not going to summarise them here (as they are effectively summaries themselves). Both worth a read though.

vb

S

 

 

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JC: Rapid update on the resus pearls of 2013. St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

Two papers on the prepublication list at the Resuscitation Journal. The first is open access (#FOAMed), and both are worth a read. There are some great resus pearls in here.

Paper 1 covers highlights in epidemiology, cardiac arrest prevention, BLS, education, defibrillation, pregnancy, trauma, drowning and avalanche (!).

Screenshot 2014-03-29 11.37.54

Paper 2 covers highlights in ALS, post resus care, prognostication and cardiac arrest centres.

Screenshot 2014-03-29 11.37.09

There’s a lot in these papers so I’m not going to summarise them here (as they are effectively summaries themselves). Both worth a read though.

vb

S

 

 

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JC: What has an awesome NNT of 5.8 for severe sepsis? St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAM

Navy ICU in Baghdad (CC Wikipedia)

ICU Wikipedia

Last week we saw the publication of the ProCESS study suggesting that protocolised treatment of sepsis makes little difference to outcome. A little earlier we heard that cooling to 33C vs 36C may not make much difference either.

Seriously, what the bally hell is going on with resuscitation these days? It seems as though interventions that we once trusted seem to make little difference and this is depressing, or is it?

There are clearly many reasons why ProCESS and TTM found few differences in their comparative therapies but what was interesting in recent trials and especially in the TTM trial was the huge difference in mortality as compared to historical controls.

The same may arguably be true of sepsis. Over the last 15 years we have seen, adopted, abandoned, reinvented, revised and reversed all sorts of treatments for severe sepsis. Have you given steroids, Protein C, starch solutions in that time? I certainly have, haven’t, have again, and then not so much. An ever changing world that seems to evade our search for the magic bullet treatment that will save our patients. The ebb and flow of treatments can create an illusion of status, a lack of direction, a lack of progress or success, but is this true.

This month there is an early publication in JAMA from Aus/NZ demonstrating a new therapy which you may have heard of, one that you’ve probably used and which you may use again and again. Not only is it familiar to you, it is arguably free, easy to access and widely available.

It also seems to work.

The Australian and New Zealand intensive care research centre have published longitudinal data on the mortality related to severe sepsis across 171 ICUs from 2000-2012. A total of 101,106 patients are included over 12 years. Read the abstract and full paper here.

sepsis 2012

This retrospective observational study is an excellent way of tracking trends for mortality for a specific condition, in this case Severe Sepsis.

Definitions are important so here SS is defined according to ACCP/SCM guidelines which should be valid, reliable and reproducible from database records. The details are well outlined in the paper with roughly a tenth of patients in the larger database of ICU admissions meeting criteria for SS.

The major results?

The principle outcome of mortality is hard to argue with, it’s important and relevant to patients, easy to measure and easy to track change over time.

Download the principle outcome graphs for mortality over time here.

So the headline results are that mortality from SS has fallen from 35% in 2000 to 18.4% in 2012. That’s a huge difference and if you want  to express it as an NNT then it works out as 5.8. In other words for roughly every 6th patient admitted to ICU in 2012 as compared to 2000, we save a life and that’s fantastic. The trend appears to be linear with mortality steadily decreasing over this time. Mortality has almost halved over 12 years

Sub analyses looking at the effect of hospital size, location, level, admission source, APACHE III score or ICU type failed to show any statistical difference in the odds ratio of risk of death. The data is pretty consistent.

My only comment on the data is that the number of patients in the study by year group similarly changes year on year. In 2000 there were only 2708 patients with sepsis in the study as compared to 12512 in 2012. I am unsure why this is. Is it because of changing referral patterns or simply an increase in the number of units reporting into the study? If the former then this may have a significant impact on results as higher admission thresholds tend to increase mortality (as we have seen with comparisons between US and European mortality rates).

So what does this tell us?

One of my EM/CC colleagues summed this paper up as ‘we’re not always sure what we are doing, but it seems to be working’. Now I think that’s a little unkind as we are always working to the best of our knowledge but it has some truths in it. As with the principles of marginal gains mentioned on this blog, step changes are rare, difficult to find and often a false dawn. This study suggests that the reasons for change are sometimes difficult to pinpoint.

TARDIS RCT anyone?

TARDIS RCT anyone?

Whether the findings are due to changes in diagnostics, therapeutics, medical, nursing, physio or procedures is not clear and the authors findings that similar reductions in mortality for non-septic patients occurred over the same time period suggest that it is the overall package of ICU care that is important. Obviously my NNT of 5.8 is clearly hypothetical as no patient with severe sepsis can wait 12 years for treatment unless the next intervention is the invention of a time machine. We must do what we can for our patients right now according to the best available knowledge that we can muster.

So, I say to my critical care colleagues, chapeaux & well done, you may not always be able to know why you are doing a great job, but the stats suggest you are.

Time is indeed a great healer and you have done well.

vb

S

 

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