Case: 24 yr male with acute alcohol intoxication brought in by ambulance. While performing some parkour stunts he fell approximately 4 meters, landing on his feet.
The Background: Nearly 50% of patients in the U.S. with cirrhotic liver disease develop ascites over a 10-year period of observation, placing them at risk for developing spontaneous bacterial peritonitis (SBP) (Runyon 2012). It is estimated that 12-25% of patients with ascites in the ED will have spontaneous bacterial peritonitis (SBP) but the classic triad of fever, abdominal pain, and worsening ascites is often absent (Borzio 2001)(Runyon 1988). With a mortality rate approaching 40%, rapid diagnosis and evidence-based treatment is critical in the management of patients presenting with SBP (Salerno 2013).
SBP is diagnosed via cell count and differential of ascitic fluid obtained by paracentesis demonstrating an elevated polymorphonuclear leukocyte (PMN) count (≥ 250 cells/mm3). Treatment focuses on appropriate antibiotic therapy. A third-generation cephalosporin is the treatment of choice as they are typically effective in covering the three most common isolates from infected ascitic fluid: Escherichia coli, Klebsiella pneumonia, and Streptococcus pneumonia (Runyon 2012). Intravenous albumin administration is often added to the management of these patients but the utility for improving morbidity and mortality is questionable. The benefit of albumin infusion in SBP is not entirely known, although multiple possible mechanisms have been identified. Albumin has been demonstrated to mitigate endotoxemia, block lipopolysaccharide-stimulated neutrophil activity, and modulate nitric oxide activity, mitigating systemic vasodilation and capillary leak (Salerno 2013).
A PubMed and MEDLINE search was undertaken to identify randomized clinical trials examining the addition of albumin therapy to antibiotics in the treatment of spontaneous bacterial peritonitis. Inclusion was limited to those studies reporting patient-oriented outcomes. Systematic reviews and meta-analyses were studied to ensure consistency and thoroughness in data reporting (Narula 2011)(Jamtgaard 2016). Four RCTs were identified as applicable, however two trials included in previous reviews were excluded, as one used hydroxyethyl starch as the comparator (Fernandez 2005) and the other examined disease-oriented outcomes such as cytokine mitigation instead of the outcomes of interest (Chen 2009). Two RCTs were ultimately identified as appropriate for inclusion and review. Additionally the most recent guidelines from the American Association for the Study of Liver Diseases (AASLD) were reviewed.
Study #1 Sort, et al. NEJM, 1999
Study #2 Xue, et al. Chin J Dig Dis, 2002
The 2012 AASLD Guidelines, based largely on the trial by Sort, et al., recommend that patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL should receive IV albumin (1.5 g/kg) within 6 hours of detection and 1.0 g/kg on day 3. (Class IIa, Level B)i
The use of IV albumin in addition to antibiotics in the treatment of patients with SBP and concomitant azotemia or hyperbilirubinemia is a lifesaving intervention of critical importance in the emergency department. As the published data and AASLD recommend administration within six hours of diagnosis, this intervention falls firmly in the hands of ED providers.
We recommend timely administration of 1.5 g/kg of albumin in addition to antibiotics in all patients presenting to the emergency department diagnosed with SBP who also have a serum creatinine >1 mg/dL, BUN >30 mg/dL, or total bilirubin >4 mg/dL.
Rick Pescatore, DO
Assistant Director of Emergency Medicine Research
Inspira Health Network
The post Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)? appeared first on R.E.B.E.L. EM – Emergency Medicine Blog.
Vocal cord dysfunction, AKA paradoxical vocal fold motion is more common than you might think. Patients often present to the Emergency Department in respiratory distress and “wheezing.” Learn about the diagnosis itself, different phenotypes and what treatment options are out there.
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Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction presenting as asthma. N Engl J Med.1983;308 :1566– 1570
Doshi D, Weinberger M. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol.2006;96 :794– 799
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007 Oct;120(4):855-64.