REMI 1992. Papel de los virus en las neumonías graves del adulto

Artículo originalViral infection in patients with severe pneumonia requiring intensive care unit admission. Choi SH, Hong SB, Ko GB, Lee Y, Park HJ, Park SY, Moon SM, Cho OH, Park KH, Chong YP, Kim SH, Huh JW, Sung H, Do KH, Lee SO, Kim MN, Jeong JY, Lim CM, Kim YS, Woo JH, Koh Y. Am J Respir Crit Care Med 2012; 15; 186(4): 325-232. [PubMed] [Artículos relacionados]
      
Introducción: El papel del virus influenza A como causante de neumonía en pacientes adultos se reforzó tras la pandemia reciente. Sin embargo, el impacto de otros virus sigue infravalorado [1, 2]. El objetivo de este estudio fue evaluar el papel de los virus en las neumonías graves del adulto.
      
Resumen: Análisis retrospectivo de una cohorte de pacientes recogida de forma prospectiva durante un año en una UCI de Corea del Sur. Se incluyeron 198 pacientes con neumonía grave (64 comunitarias y 134 asociadas a cuidados sanitarios). El 90% estaban ventilados y el 10% eran inmunocomprometidos. No se modificó la práctica clínica habitual del servicio por lo que entre otras pruebas diagnósticas, se realizó frotis faríngeo al 80% de los pacientes y lavado broncoalveolar (LBA) al 60%. Los virus se identificaron mediante técnicas de PCR utilizando un kit comercial capaz de detectar 16 virus distintos. Hasta en el 35% de los pacientes se objetivó una infección vírica y en otro 35% una infección bacteriana. Los principales virus identificados fueron rinovirus, parainfluenza, metapneumovirus e influenza. Las neumonías víricas presentaron mayor afectación pulmonar bilateral y marcadores inflamatorios menos elevados que las bacterianas. La mortalidad entre los dos grupos fue similar. Los autores concluyen que un tercio de sus neumonías graves, comunitarias o relacionadas con cuidados sanitarios, están ocasionadas por virus y su mortalidad es similar a la de las bacterianas.
      
Comentario: A pesar de que el estudio presenta varias limitaciones como son la no realización sistemática del LBA y la utilización de kits multidetectores cuya sensibilidad es menor que la detección individual, es evidente el cada día mayor reconocimiento del papel de los virus en las infecciones respiratorias. Otro estudio reciente lo corrobora [3]. Los datos de este estudio sugieren que, a pesar de la falta de tratamiento para la mayoría de virus, deberíamos empezar a plantearnos su detección como parte del diagnóstico diferencial de estas infecciones, lo que podría ayudarnos a limitar el uso indiscriminado de antibióticos.
      
Ferran Roche Campo
Hospital Verge de la Cinta, Tortosa, Tarragona.
© REMI, http://medicina-intensiva.com. Septiembre 2014.
     
Enlaces:
  1. Viruses associated with pneumonia in adults. Cesario TC. Clin Infect Dis 2012; 55: 107-113.  [PubMed] [PDF]
  2. What is the role of respiratory viruses in community-acquired pneumonia?: What is the best therapy for influenza and other viral causes of community acquired pneumonia? Pavia AT. Infect Dis Clin North Am 2013; 27: 157-175. [PubMed] [PDF]
  3. Lower Respiratory Tract Virus Findings in Mechanically Ventilated Patients With Severe Community-Acquired Pneumonia. Karhu J, Ala-Kokko TI, Vuorinen T, Ohtonen P, Syrjälä H. Clin Infect Dis 2014. [PubMed]
Búsqueda en PubMed:
  • Enunciado: Virus y neumonía 
  • Sintaxis: Viral infection AND community pneumonia in adults AND intensive care 
  • [Resultados]
        

Patient Satisfaction: It’s Door-to-Room Times (Duh)

As customer satisfaction becomes rapidly enshrined as our reimbursement overlord, we are all eager to improve our satisfaction scores.  And, by scores, I mean: Press Ganey.

So, as with all studies attempting to describe patient satisfaction, we unfortunately depend on the validity of the proprietary Press Ganey measurement instrument.  This limitation acknowledged, these authors at Oregon Health and Science University have conducted a single-center study, retrospectively linking survey results with patient characteristics, and statistically evaluating associations using a linear mixed-effects model.  They report three survey elements:  overall experience, wait time before provider, and likelihood to recommend.

Which patients were most pleased with their experience?  Old, white people who didn’t have to wait very long.  Every additional decade in age increased satisfaction, every hour wait decreased satisfaction, and there was a smattering of other mixed effects based on payor source, ethnicity, and perceived length of stay.  What’s interesting about these results – despite the threats to validity and limitations inherent to a retrospective study – is how much the satisfaction outcomes depend upon non-modifiable factors.  You can actually purchase patient experience consulting from Press Ganey, and they’ll come teach you and your nurses a handful of repackaged common-sense tricks – but I’m happy to save your department the money:  door-to-room times.

Or change your client mix.

Done.

“Associations Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in an Adult Population”
http://www.ncbi.nlm.nih.gov/pubmed/25182541

Don’t become Jaundiced about POCUS

This patient came in with jaundice and the LFTs were elevated. They had had a cholecystectomy in the past. POCUS revealed a large dilated fluid-filled structure in the RUQ. After looking at the kidneys/liver +/- Doppler it became clear it was a very dilated CBD. CT confirmed the biliary dilatation and obstructing mass. [Ed. note: Great call by Lloyd. The CBD is a bit tougher to identify without a gallbladder present. For one thing, you lose the exclamation in the exclamation point sign. For another, the CBD is often dilated post-choly and can look like the portal vein. Color Doppler is key. No flow = CBD. This CBD is massive!]

CBD

Biliary

Patient found down with WCT Episode 158 September 8,…



Patient found down with WCT
Episode 158

September 8, 2014


Causes of QRS prolongation
  • Ventricular ectopy
  • BBB (LBBB or RBBB) or paced rhythm
  • Pre-excitation (WPW)
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Medication toxicity ​
  • Nonspecific intraventricular conduction delay (eg. LVH)
​What about the causes of Really Wide QRS complexes?
  • Think of toxicologic and metabolic (hyperkalemia & severe acidosis) causes
  • Consider Calcium and Sodium Bicarbonate therapy before antiarrhythmics

Do your remember your differentials for Right Axis Deviation? How about the classic findings of TCA toxicity?

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Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED

AFibIntravenous beta blockers and non-dihydropyridine calcium channel blockers are recommended first-line for atrial fibrillation (AF) with rapid ventricular rate (RVR) [1]. In a previous post, Bryan Hayes (@PharmERToxGuy) provided an overview of the data comparing beta blockers to calcium channel blockers for atrial fibrillation rate control in the ED. Here is part 2 of our two-part AF series.  

Thinking Beyond the Emergency Department

Although clinicians are cautioned regarding their use in heart failure or hypotension, minimal guidance is provided on which of the two classes is most appropriate in an individual patient. While acute rate control is certainly an important therapeutic goal for patients in AF with RVR, consideration of the patient’s comorbid conditions may be just as important for determining which drug class represents a more viable long-term solution. As a consequence, judicious selection of initial therapy may therefore avoid unnecessarily prolonging a patient’s hospitalization while therapy is transitioned. The following are several common comorbidities of AF where one agent may be more ideal over another:

1. Heart failure

Both beta blockers and non-dihydropyridine calcium channel blockers exert negative inotropic effects in the acute setting and should therefore be used with caution in patients with heart failure with reduced ejection fraction (HFrEF). However, long-term beta blocker use confers significant improvements in survival whereas non-dihydropyridine calcium channel blockers either exert no beneficial effects or may even worsen outcomes [2-4]. For these reasons, the use of non-dihydropyridine calcium channel blockers should generally be avoided in patients with HFrEF despite minimal differences in their acute risks [5].

2. Ischemic heart disease

Although both classes are associated with improvements in major adverse cardiovascular events in patients with a history of myocardial infarction (MI), only beta blockers have been associated with reductions in the incidence of ventricular arrhythmias and sudden cardiac death [3, 4, 6]. Notably the benefits of beta blockers in the post-MI setting appear to attenuate over time, though they remain a standard of care and should be favored over non-dihydropyridine calcium channel blockers. The latter remain an option in patients with chronic stable angina or those whose symptoms are refractory to maximally-tolerated doses of beta blockers.

3. Hypertension

Along with angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and thiazide diuretics, calcium channel blockers are recommended as a first-line option for patients with high blood pressure [7]. Their use as initial therapy is especially advocated in black patients (although thiazides are a viable alternative), given improvements in long-term cardiovascular events compared to inhibitors of the renin-angiotensin-aldosterone system [8]. Beta blockers should be reserved for patients whose blood pressure remains uncontrolled despite use of the four preferred drug classes (ACEi or ARB, thiazide, or calcium channel blocker) given evidence from trials that they are less effective at preventing cardiovascular events [7]. Therefore, in patients with concomitant high blood pressure who may benefit from additional blood pressure lowering, calcium channel blockers may be a more ideal option for rate control. The addition of a nondihydropyridine calcium channel blocker should generally be avoided in patients who are already receiving a dihydropyridine calcium channel blocker (e.g., amlodipine, nifedipine), as only a minimal incremental impact on blood pressure is observed.

4. Pulmonary disease

Calcium channel blockers should be favored over beta blockers in patients with asthma (or other forms of pulmonary disease with a bronchospastic component) given the risk of exacerbating bronchospasm. However, beta blockers need not be avoided in patients with chronic obstructive pulmonary disease (COPD) given lack of evidence to indicate harm and a potential benefit [9, 10].

5. Others

Clinicians may be cautioned against using beta blockers in a number of other disease states, including diabetes mellitus, peripheral vascular disease, depression, and erectile dysfunction. However, in each case minimal evidence supports the risk of exacerbating disease and in most cases the benefits of therapy outweigh risks. That being said, a calcium channel blocker would be an acceptable choice in any of these conditions in the absence of compelling indications for beta blocker therapy.

Bottom line

Both beta blockers and calcium channel blockers appear safe and effective for acute rate control in AF with RVR. However, given the compelling benefits of one class over the other in several common comorbidities, initial selection should take these factors into consideration so that the medication chosen can represent both a short- and long-term solution.

References

  1. Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, et al. Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations) A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 May 7;127(18):1916–26.  Pubmed
  2. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7. Pubmed
  3. Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85. Pubmed
  4. The Multicenter Diltiazem Postinfarction Trial Research Group. The effect of diltiazem on mortality and reinfarction after myocardial infarction.  N Engl J Med. 1988 Aug 18;319(7):385-92. Pubmed
  5. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Oct 15;62(16):e147-239. doi: 10.1016/j.jacc.2013.05.019.  Pubmed
  6. Turi ZG,Braunwald E.The use of beta-blockers after myocardial infarction. JAMA.1983 May 13;249(18):2512-6. Pubmed
  7. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA J Am Med Assoc. 2014 Feb 5;311(5):507–20. Pubmed
  8. Leenen FHH, Nwachuku CE, Black HR, Cushman WC, Davis BR, Simpson LM, et al. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension. 2006 Sep;48(3):374–84.  Pubmed
  9. Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549. Pubmed
  10. Rutten FH, Zuithoff NP, Hak E, Grobbee DE, Hoes AW. Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease. Arch Intern Med. 2010 May 24;170(10):880-7.  Pubmed

Edited by Bryan D. Hayes, PharmD, FAACT

Author information

Brent Reed, PharmD, FAHA

Assistant Professor of Cardiology

University of Maryland School of Pharmacy

Creator of The Unit, a blog with perspectives on cardiology practice, health care, and the profession of pharmacy

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