Tag Archives: rushton

massive transfusion

8 Aug

RAGING HYPOTHETICAL:

A 25 yo male is accidentally pinned against the wall by a relative who mistook the gas pedal for the brake pedal. He presents in shock, has a shattered pelvis and requires a massive amount of blood products. What products do you order, and at what ratio?

Borgman, Matthew et al.

Question: What is the correct ratio of FFP/PRBC in a patient requiring massive transfusion?

Methods: Retrospective study of military patients in US military hosptals who received >10 units of PRBC. Their survival was recorded and compared to the ratio of FFP/PRBC

 

Results: The low ratio group (1.4uFFP/1uPRBC) had a statistically significant survival benefit even when adjusting for the degree of injuries.

Teaching Point: In Massive Transfusion, aggressive use of FFP on a 1/1 ratio can be associated with decreased mortality.

Submitted by W. Rushton.

Reference(s): Borgman, Matthew et al. “The Ratio of Blood Products Transfused Affects Mortality in Patients Receiving Massive Transfusions at Combat Support Hospital” Journal of Trauma October 7, 2007, Vol 63; picture

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OSA and Risk of Hypertension

7 Aug

Mairin et al:

Question: Several studies link OSA (obstructive sleep apnea) to hypertension and risk of CV disease. Is CPAP treatment effective at mitigating these risks?

Methods: A prosepective study of 1889 participants without HTN were referred to a sleep center in Spain. SBP >140 or being placed on an anti-hypertensive at the 1 year follow up visit was documented and compared against rates of the general population

Results: 37% of the OSA-ers developed HTN.

The ratios are as followed:

 –National Control: 2.19persons/100 (1.7-2.67)

 –OSA ineligible for CPAP tx: 3.34 (2.85-3.82)

 –OSA declined CPAP tx: 5.84(4.8-6.8)

 –OSA treated with CPAP 3.06 (2.7-3.4)

Teaching points:

Patients with OSA were at increased risk for the development of HTN. Successful placement on CPAP however mitigated the risk of developing HTN.

When risk stratifying our patients in the acute setting for CV disease, it is important to know if they are compliant with their CPAP.

Submitted by W. Rushton.

Reference(s): Mairin et al. “Assoication Between Treated and Untreated OSA and Risk of Hypertension” JAMA May 23/30 2012 VOL 307, No 20; picture

To what goal should non hemorrhaging patients be transfused?

6 Aug

RAGING HYPOTHETICAL:

A 82 yo multiple myeloma pt with a CAD history is transferred from the cancer center where her Hgb was found to be 6. There is no signs of active bleeding. You give her 2 units PRBC in the ER and admit her to heme/onc.  Is that enough blood?

Hebert, Paul et al.:

Question: To what goal should non hemorrhaging patients be transfused?

Methods: 838 critical care patients were enrolled and were randomized to a HGB of 7-9 or 10-12 goal. 30 day mortality was followed.

Results: Hgb 7 vs 10

No statistically significant difference in 30-day or 60-day mortality

–On average, the restrictive groups used 54% less product

–Expert opinion improved outcomes in patients with acute MI and unstable angina with liberal approach

–Not statistically significant

Teaching Point: Transfusing patients to an H/H goal of 7/21 has no change in mortality as 10/30 and can significantly reduce the amount of blood products required.

Submitted by W. Rushton.

Reference(s): Hebert, Paul et al. “A Multicenter Randomized Controlled Clinical Trial of Transfusion Requirements in Critical Care” NEJM 2/11/199 Volume 340, No 6; picture

Can you safely discharge a minor head trauma patient on coumadin after a negative head CT?

2 Aug

RAGING HYPOTHETICAL:

A 84 yo male on Warfarin for AFIB presents s/p a fall when getting out of a car and landing on his head. He had a questionable LOC. Initial Head CT is negative. INR is 3.1. What now?

Menditto et al:

Question: Can you safely discharge a minor head trauma patient on coumadin after a negative head CT?

Methods: 97 patients on coumadin were admitted after a negative head CT and had a second head CT 24 hours later at discharge

Results:

5 patients had a new hemorrhage and 1 required a craniotomy.

Two patients were later admitted with a new head bleed at days 2 and 8.

4/7 patients had an INR >3.

Teaching point:

Pts on coumadin with minor head trauma and a negative head CT have a small but real risk of developing a head bleed.

However, as the accompanying editorial to this article points out only one patient required surgery.

The risk benefit must be tailored by the physician but an elevated INR increases the risk of developing an ICH.

Submitted by W. Rushton.

Reference(s): Menditto et al. “Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24 hour Observation Protocol” Annals of Emergency Medicine Volume 59, No 6. June 2012; picture

magnesium sulfate for acute asthma

1 Aug

RAGING HYPOTHETICAL:

A 19 yo male with severe asthma and known to be non compliant with his medications presents in severe dyspena and wheezing. His dyspnea is only minimally improved with multiple continuous nebulizers.  Steroids given, but will take time to kick in. Patient is still wheezing severely. Now what?

Rowe BH et al:

Question: What is the evidence supporting magnesium in asthma exacerbation?

Methods: 7 RCTs (5 adult studies, 2 peds) were identified by doing a MEDLINE and Cochrane search

Results:

There was no statistical difference in hospital admission in Mg vs no Mg [OR] 0.31, 95% confidence interval [CI] 0.09 to 1.02).

Overall, patients receiving magnesium sulfate demonstrated nonsignificant improvements in PEFR when all studies were pooled.

The absolute FEV(1) also improved by 10% predicted (95% CI 4 to 16) in patients with severe acute asthma.

No clinically important changes in vital signs or side effects were reported.

Teaching Point: The absolute benefits of magnesium as still unproven. However, the severe nature of the disease and the relative reduced side effects of magnesium makes treatment with the medication a reasonable choice.

Submitted by W. Rushton.

Reference(s): Rowe BHet al“Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.” Ann Emerg Med. 2000 Sep;36(3):181-90.; picture

vasopressors in shock

31 Jul

De Backer D et al.:

Question: In the treatment of shock, is one vasopressor more efficacious than another?

Methods:

RCT all comers with shock were assigned to receive either dopamine or norepinephrine as first-line vasopressor therapy.

When hemodynamic monitoring could not be met, open label epi, norepi, or vasopressin was added.

The primary outcome was the rate of death at 28 days; secondary end points included the occurrence of adverse events.

Results:

There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10).

However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001).

Teaching point: While both dopamine and norepi had no change in mortality, dopamine was associated with statistically more adverse effects (usually afib) and dopamine pts more often had to be put on open label second agent.

Submitted by W. Rushton.

Reference(s): De Backer D et al. “Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010 Mar 4;362(9):779-89.; picture

initial presentation of MI in women and older patients

30 Jul

Canto et al:

Question: Is there actually a difference in initial presentation of MI among women and older patients?

Methods: Observation study from the National Registry Myocardial Infarction of 1,143,513 patients from 1994-2006

Results: Proportion of female patients who presented without chest pain (42%) was significantly higher than men (30.7%) P<0.001. Absence of chest pain was also correlated with increased mortality (due to delay in recognition of MI).

Teaching points: Have a high index of suspicion for women with vague complaints as a ~40% of female MI patients will not have chest pain.

Submitted by W. Rushton.

Reference(s): Canto et al, “Association of Age and Sex with MI Symptom Presentation and In-Hospital Mortality” JAMA February 22 Vol 307 No 8; picture