How low should you go? MAP Goals in Septic Shock

Background:

• Since Rivers’ Early-Goal Directed Therapy, a MAP of 65 mm Hg was been the standard goal for blood pressure in septic shock
• Some studies have suggested a higher target may be better for patients with hypertension
• Potentially less renal failure with a higher target

The Trial:

• 776 adult patients in France; Multi-center; randomized; non-blinded
• All patients had septic shock and on vasopressors
• MAP was maintained for 5 days or when the patient was weaned off pressors
• Primary outcome: Mortality at Day 28
• High target 65-70 mm Hg vs Low target 80-85 mm Hg

Outcome:

• No significant difference in mortality at 28 days: 36.6%  (high target) vs 34% (low target) (95 %CI; 0.84 to 1.38; P=0.57)
• No significant difference at 90 days: 43.8% (high target) vs 42.3% (low target) (95% CI; 0.83 to 1.30; P=0.74)
• Incidence of newly diagnosed atrial fibrillation was higher in the high-target group
• Patients with chronic hypertension: those in the higher target group required less renal-replacement therapy
• Significant percentage of patients in the high target group did not meet goal MAP BUT the trial mirrored actual clinical practice and allowed clinicians the ability to limit blood pressure and differences in actual MAP attained in both groups was significantly different

Bottom Line:

• A MAP goal of 65 is just fine in most patients
• Patients with chronic hypertension and atherosclerosis seem to benefit (less need for renal-replacement therapies) with a higher MAP: so aim higher in these patients or monitor renal function and increase MAP goals accordingly

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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

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Perinatally Infected HIV & Cardiovascular Disease

*Perinatally HIV-infected adolescents are susceptible to aggregate atherosclerotic cardiovascular disease risk, but few studies have quantified risk or developed a scoring system

*A recent study of perinatally HIV-infected adolescents calculated coronary artery and abdominal aorta PDAY (Pathobiological Determinants of Atherosclerosis in Youth) scores using modifiable risk factors: HTN, HLD, smoking, obesity and hyperglycemia

*Significant predictors of a high coronary arteries and abdominal aorta scores include: male sex, Hx AIDS-defining condition, long duration of ritonavir-boosted protease inhibitor, and no prior use of tenofovir

*PDAY scores may be useful in identifying high-risk youth who may benefit from early lifestyle or clinical interventions given their trend of increased aggregate atherosclerotic cardiovascular disease risk factor burden

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A new study of almost 2 million prescriptions in VA patients compared the risk of cardiovascular death or dysrhythmia in patients receiving azithromcyin, levofloxacin, and amoxicillin.

What they found

Compared with amoxicillin, azithromycin was associated with a significant increase in mortality (HR = 1.48; 95% CI, 1.05-2.09) and dysrhythmia risk (HR = 1.77; 95% CI, 1.20-2.62) on days 1 to 5, but not 6 to 10.

Levofloxacin was associated with an increased risk throughout the 10-day period. Days 1-5 mortality (HR = 2.49, 95% CI, 1.7-3.64) and serious cardiac dysrhythmia (HR = 2.43, 95% CI, 1.56-3.79). Days 6-10 mortality (HR = 1.95, 95% CI, 1.32-2.88) and dysrhythmia (HR = 1.75; 95% CI, 1.09-2.82).

Important limitations

This study did not have a comparator group of patients getting no antibiotics. Previous data suggest patients on any antibiotic (eg, penicillin) have a higher risk of death or dysrhythmia.

The supplemental index shows that patients receiving azithromycin and levofloxacin had more serious infections (eg, PNA, COPD, etc.) which may have put them at higher risk for worse outcome irrespective of antibiotic choice.

What it means

It seems azithromycin and levofloxacin may contribute to a small increase in cardiovascular mortality and dysrhythmia during their use. A previous study found this is more likely in those with existing cardiovascular disease.

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• Naloxone has technically always been able to be prescribed by physicians to individual patients.
   
• New laws however, make it acceptable for prescribers in many states to prescribe naloxone to “third parties,” e.g parents, friends, etc. of patients, with the assumption that the overdosed patient will not be capable of administering the antidote to themselves.

• Many states are offering short 10-20 minute training sessions on how bystanders can administer the reversal agent to the patient who has overdosed.

• If prescribed, it should be prescribed to the individual who completed the training, not the intended patient, and may be written for intranasal or intramuscular administration.

• Intranasal (IN) is “off label” and an approved intranasal preparation is not commercially available, but the intramuscular preparation can be prescribed along with an atomizer device. The usual IN dose is 1 mg per nostril which may be repeated in 3-5 minutes.

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Question

You are working in a clinic in Tanzania (or Baltimore, for that matter) when a 24 year old presents with this itchy rash on his feet.  What's the diagnosis and what underlying systemic condition does it indicate?

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Attachments

1404012249_HIV-Associated_Puritic_Papular_Eruptions.JPG (2,920 Kb)

Coagulopathies in Critical Illness - DIC

• Disseminated intravascular coagulation (DIC) is an acquired syndrome of intravascular coagulation and is commonly encountered in critically ill patients.
• Think about DIC in the critically ill patient with oozing at vascular sites (or wounds) and the following lab abnormalities:
  • Thrombocytopenia
  • Prolonged PT and aPTT
  • Decreased fibrinogen
  • Elevated fibrin split products and D-dimer
• Guidelines for the management of DIC are primarily based on expert opinion and include:
  • Treat the underlying condition (i.e., sepsis)
  • Transfuse platelets if < 50,000 per mm³
  • Transfuse FFP to maintain PT and aPTT < 1.5 times normal control
  • Transfuse cryoprecipitate to maintain fibrinogen levels > 1.5 g/L
• The use of heparin remains controversial and cannot be routinely recommended.

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Question

25 year-old female presents with the following. It seems to have occurred spontaneously and spontaneously resolves during her ED evaluation.

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DeQuervain and Intersection Syndromes:
 

• DeQuervain's Syndrome (Tenosynovitis of the Abductor Pollicus Longus and Extensor Pollicus Brevis tendons) is a common disorder that has received a lot of press lately as BlackBerry Thumb or Gamer's Thumb.
  • This condition can be diagnosised by the Finklestein test [Have the patient bend their thumb into the palm of their hand, and then make a fist.  They should then ulnar deviate their wrist.  Pain along the tendons secures the diagnosis.]
  • The pain of DeQuervain's syndrome is typically along the distal end of the radius at the base of the thumb.
• Intersection syndrome is a less common disorder though closely related to DeQuervain's Syndrome
  • The pain is usually felt on the top of the forearm about three inches proximal to the wrist. 
  • The pain from this condition is due to tenosynovitis of the Extensor carpi radialis longus and Extensor Carpi radialis brevis muscles/tendons caused by the intersection of them with the Extensor pollicus brevis and Abductor pollicus longus tendons.
  • Occurs due to excessive wrist movements.
  • Intersection syndrome can be seen in weight lifters, skiers, and can be seen in homeowners in the fall and winter when they rake a lot of leaves or shovel snow.
• Treatment is the similar for both conditions and consists of:
  • NSAIDS
  • Cortisone injections can be effective
  • Thumb and wrist immobilization with a Thumb Spica Splint or Cock Up Wrist Splint

What are characteristics that increase the chance a patient is at risk for opioid-related death? A recent JAMA article begins to tackle this very issues. Baumblatt et al. found the following:

1) Patient with 4 or more prescribers had adjusted odds ratio 6.5 for opioid-related death

2) Patient with 4 or more pharmacies where they get their prescriptions aOR - 6.0

3) Patient with more than 100 mg of morphine equivalents mean per day aOR - 11.2

With the new Maryland Prescription Drug Monitoring program (PDMP)  we can start looking at a patient's prescription drug use pattern. The recent JAMA article can help you identify patients at high risk to die an opioid-related death. Use the PDMP and be wary if a patient has more than 4 prescribers or pharmacies or has >100mg of morphine equivalents per day.

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Question

You are evaluating a 40 year old trauma victim and see this on pelvic xray. What are you worried about?

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