UMEM Educational Pearls - By Neeraja Murali

How many times have you discharged a patient with a clinical impression of “abdominal pain” with no clear explanation or diagnosis? 

How many of these times do you direct them to follow up with gastroenterology? And more importantly, how often do they actually do so?

This study discussed a multi-disciplinary approach to ensuring adequate follow up for patients, utilizing an EMR based transition of care (TOC) program. The study stratified patients into 2 groups, pre and post TOC program implementation, to assess rates of appointment scheduling and attendance, as well as rates of return to ED within 30 days. Patients were further stratified based on their Distressed Communities Index (DCI) score (a composite of 7 different socioeconomic metrics) into 5 tiers: Distressed Communities, At Risk Communities, Mid-Tier Communities, Comfortable Communities, and Prosperous Communities. Prior to the implementation of the TOC program, the onus was on the patient to schedule their appointment. The TOC program consisted of an order placed in EMR, which triggered review of the patient's chart by the gastroenterology attending or NP. This individual would then message the information to the appropriate GI subspecialty clinic, along with a time frame in which the patient should be seen. The clinic would then check the patient's insurance reach out to the patient directly to schedule the appointment.

While there was no signifcant difference in 30-day readmission between the pre and post TOC program patients, the post-implementation group was found to both schedule appointments (50% vs 27% p-value <0.01) AND show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. Additionally, post-TOC patients in the At-Risk and Distressed DCI groups were 22x more likely to follow up than the same groups in the pre-TOC group (OR 22.18, 95% CI 4.23–116.32).

Though the study had promising results, it did admittedly have some limitations, namely the size of the at-risk and distressed groups.  Another consideration, though not mentioned in the paper, is that access to a working phone is necessary to the success of this program. Nevertheless, the idea of a TOC program is worth consideration as a means to ensure that patients are not lost to follow up and potentially reduce the risk of adverse events.

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This retrospective cohort study examined patients over a one year period to evaluate factors associated with unfavorable outcomes in acute abdominal pain. 

Unfavorable outcomes were defined as any of the following: 1) shock requiring an invasive procedure such as central line insertion or mechanical ventilation 2) emergency surgery 3) post-operative complications OR 4) in-hospital cardiac arrest

951 patients were included in the study. 

Physical exam and laboratory signs associated with the above unfavorable outcomes included:

-diastolic BP < 80 mmHG

-RR ? 24/min

-RLQ tenderness

-abd distension

-hypoactive bowel sounds

-presence of specific abdominal signs (ie Murphy's sign, psoas sign, etc).

-leukocytosis

-ANC >75%

Further, ED Length of Stay of > 4 hours was also associated with unfavorable outcomes.

Food for thought when considering serial abdominal exams when diagnosis is unclear…

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Think before placing a nasogastric tube!

Multiple articles which discussed complications of NGT placement were included in this integrative review, with the majority (n=67) publishing results in English. The authors categorized adverse events into two broad categories:

1) Mechanical adverse events - including respiratory, esophageal, and pharyngeal complications, obstructed tube, intestinal and intracranial (!) perforation, and tube withdrawal 

-The largest cohort (n=44) was respiratory, with displacement or placement of tube to the respiratory tract

2) Others - pressure injury and misconnection

-One study showed pressure related injury in 25%, and 5 articles discussed complications of misconnection (including extravasation of gastric fluids and inadvertent connection to central venous catheters)

16 of the 69 studies reported death as a consequence of improper placement. 

One big takeaway: there is no universally accepted standard for verificaiton of tube placement. Xray is considered to be *most* accurate. Tubes should also be checked periodically and depth should be marked. Evidence-based guidelines need to be developed to improve patient safety, outcomes, and quality of care.

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Diverticular disease is a common condition, with 60% of individuals over age 80 and 30% of those over age 45 (!) having diverticula. Recent estimates show that 10-25% of this subset with suffer at least one episode of acute diverticulitis in their lifetime. Fortunately, the majority of these cases are uncomplicated. This study provides evidence that outpatient treatment of acute diverticulitis is reasonable. 

Study Design:

The DINAMO study was a multicenter randomized open-label non-inferiority trial evaluating the utility of antitbiotics in uncomplicated diverticulitis. The study included adult patients with uncomplicated diverticulitis without significant comorbities. The diagnosis was based on modified Neff classification with patients with a mNeff of 0 being included. Eligible patients were randomized to one of two treatment groups:

1) 600 mg ibuprofen q 8 h alternating with 1000 mg of acetaminophen q 8 h x7 d (Exerimental arm) OR

2) 875/125 mg amoxicillin/clavulanate q 8 h x 7 d in addition to the above (Control arm)

Outcomes of interest and Results: 

Any patients who returned to the hospital underwent repeat CT. Primary of outcome of interest was admission to the hospital on revisit, with secondary outcomes being revisit itself, follow up, pain control, and recovery

There was no statistically significant difference in any of these (for numbers, please refer to article 1 linked below); further, no patients required emergency surgery. 

Implications:

There is a low likelihood ot treatment failure when antibiotics are avoided in acute uncomplicated diverticulitis. This study finds this treatment regimen ot be noninferior to antibiotic treatment in terms of hospital admission, revisit rates, and recovery.  Consider this treatment regimen in eligible patients. 

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In recent years, there has been an uptick in non-operative management of acute appendicitis. This study examins outcomes in older patients (>65 years old).

The study authors evaluated retrospective data and included 474845 patients in the US with acute uncomplicated appendicitis betwen 10/2021 and 04/2022. All participants survived at least 24 hours postoperatively and none carried a diagnosis of inflammatory bowel disease; there were 43,846 patients treated nonoperatively and 430,999 who underwent appendectomy. The primary outcome was incidence of post-treatment complications, with secondary outcomes of mortality, length of stay, and inpatient costs. 

In patients 65+, there was a 3.72% decrease in risk of complications, 1.82% increase in mortality, and increased LOS and costs. 

Ultimately, operative management of acute appendicits was associated with reduced mortality, length of stay, and costs across all adult patients. While nonoperative management remains an option in the treatment of acute appendicits, surgical management continues to be the accepted standard. 

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Question

Bottom Line: With the increasing acceptance and legalization of marijuana and its derivatives, emergency departments have seen an increase in patients with cannabis hyperemesis syndrome (CHS). In this patient population, when other pathologies have been excluded, consider droperidol (0.625 mg – 2.5 mg) or haloperidol (0.05 mg/kg or 0.1 mg/kg) for management of symptoms.

Two separate articles were reviewed for this pearl. One is a systematic review of existing literature, and the other is a randomized controlled trial.

The systematic review examined 17 existing studies, including case reports, RCTs, retrospective studies, and other systematic reviews. This included adults aged 18-85 who were using recreational or medicinal cannabinoids. There was a consensus that cessation of cannabinoid use is the best way to alleviate symptoms of CHS. Other options discussed include: 

1. Hot water hydrotherapy (ie hot baths or showers), which redirects blood flow to the skin and activates a vanilloid receptor which releases substance P, a neuropeptide associated with inflammation and pain. While this provides temporary relief of symptoms, the receptor can become unresponsive with chronic THC exposure. Only qualitative evidence was available for this therapy.
2. Topical capsaicin cream, which is theorized to have a similar mechanism as hot water hydrotherapy. 0.025-0.1% creams were discussed, with studies agreeing on shorter length of stay and improvement in nausea and vomiting; however all studies used small cohorts (of 4 or less).
3. Droperidol is a short-acting dopamine antagonist. In a systematic review, use of 0.625-2.5 mg of IV droperidol was the only treatment showed a statistically significant difference in visual analog scale when compared to placebo. Use of droperidol also results in shorter length of stay and decreased need for other anti-emetics.
4. Benzodiazepines have limited evidence, but one case study of four patients showed 2 doses of 0.5 mg clonazepam lead to rapid relief of symptoms and discharge within 24 hours.
5. Haloperidol is another dopamine antagonist with good eppicacy in cessation of nausea vomiting. Various studies have been performed, with most being case studies, with varying doses recommended. One study was a randomized controlled trial, more on this below.
6. Propranolol was discussed in a single case study, with two doses 1 mg IV given one hour apart leading to complete resolution of symptoms. This was the only such case study in the body of literature.
7. Aprepitant is a neurokinin1 receptor agonist and acts similar to capsaicin with regards to substance P. A case report discussed a patient that was refractory to all other treatments; however, a dose was not described.

As mentioned above, the HaVOC study examined various doses of haloperidol versus odansetron. This randomized controlled trial was triple blinded and had three groups: haloperidol 0.05 mg/kg or 0.1 mg/kg or odansetron 8 mg IV. The outcome of interest was reduction in abdominal pain and nausea at two hours after treatment. Either dose of haloperidol was found to be superior to odansetron, with improvements in pain and nausea (54% versus 29%; 95% CI -16% to 59%), and less use of rescue antiemetics (31% versus 59%, with 95% CI -61% to 13%). Haloperidol also resulted in shorter ED length of stay (3.1 h vs 5.6 h, 95% CI 0.1-5.0 h, p=0.03). However, 2 patients in the high dose haloperidol group had dystonic reactions precipitating return visits. The study does not specifically discuss differences in outcomes between the high and lower dose haloperidol groups.

Neither paper discussed the best alternatives when QTc prolongation is of concern. Clinicians should use their best judgment and the available information when deciding on a treatment option.

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