Welcome back to Episode 41 of REBEL Cast. In this episode, we will be discussing some studies from the past year that caught our attention in the area of resuscitation. Again, this 3 part series will be dedicated to discussing current literature and how it can be applied to your clinical practice.
Episode 41 – Research From the Past Year – Resuscitation
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Study #1:
Veld HI et al. Ultrasound Use During Cardiopulmonary Resuscitation is Associated with Delays in Chest Compressions. Resuscitation 2017. PMID: 28754527
Blog Post HERE: Impact of POCUS During Cardiac Arrest Resuscitation on Compression Pauses
- Prospective Cohort study of 23 cardiac arrest patients
- POCUS during Rhythm check vs No POCUS During Rhythm Check
- Duration of Pulse Check
- With POCUS: 21.0 sec
- Without POCUS: 13.0 sec
- Diff: 8 seconds
Bottom Line: Intra-arrest POCUS may increase the duration of rhythm checks which has the potential to worsen outcomes. Providers should be cautious to not allow POCUS to interfere with interventions proven to be beneficial (compressions and defibrillation). More research is required to investigate why interruptions are longer, potential benefits of POCUS in arrest and the impact of prolonged pauses in this situation.
Study #2:
Konstantinides SV et al. Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017. PMID: 28335835
Blog Post HERE: Do All Submassive PE’s Require Treatment With Thrombolysis
- Long-term Prognosis of patients from PIETHO trial (multicenter, double-blind, placebo controlled randomized trial) of 1005 patients tenecteplase versus placebo in normotensive patients with acute PE, RV dysfunction, positive troponin = Intermediate/Submassive PE
- Original Trial: Decrease in 7 day hemodynamic compromise but with increased intra- and extra-cranial bleeding
- These modest benefits come at a 10-fold increase in intracranial hemorrhage (ICH) and a 5-fold increase in major bleeding
- Now the Follow Up Trial of 709 patients from original PEITHO Trial with Median Follow up of 37.8months (2 – 3 year)
- No difference in mortality or persistent clinical symptoms
Bottom Line: In the current trial, long-term mortality rates and long-term morbidity (residual dyspnea, functional limitations, and persistent RV dysfunction) were not affected by the use of systemic thrombolysis in unstratified patients with submassive PE. Thrombolysis in submassive PE should now only be considered in patients with signs of submassive PE and either at risk of throwing additional emboli to the lungs (proximal DVT or clot in transit on echo) or patients who appear to be at the brink of massive PE (pale, diaphoretic).
Study #3:
Girardis M et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen ICU Randomized Clinical Trial. JAMA 2016. PMID: 27706466
Blog Post HERE: February 2017 REBEL Cast – The All Hyperoxia Edition
- Single center, RCT all adults admitted to ICU for ≥72hours
- 434 patients (Stopped enrollment due to earthquake)
- Conservative O2 (PaO2 70 – 100mmHg or SpO2 94 – 98%) vs Standard Conventional O2 (PaO2 up to 150mmHg or SpO2 97 – 100%)
- Conventional vs Conservative O2
- Mortality: 20.2% vs 11.6% (NNT = 12)
- Shock: 10.6 vs 3.7%
- New Organ Failure: 25.7% vs 19.0%
- Needed 660 patients to detect an absolute difference in 6% (Recruitment stopped at 480 patients due to an earthquake)
- Bottom LIne: In critically ill ICU patients, FiO2 should be titrated to maintain normoxia as supraphysiologic levels appear to increase mortality.
Well that’s it for part 2 of this 3 part series. Stay tuned as Swami and I are going to tackle some more papers published in the past year that we think you should know about. 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:
- Veld HI et al. Ultrasound Use During Cardiopulmonary Resuscitation is Associated with Delays in Chest Compressions. Resuscitation 2017. PMID: 28754527
- Konstantinides SV et al. Impact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017. PMID: 28335835
- Girardis M et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen ICU Randomized Clinical Trial. JAMA 2016. PMID: 27706466
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