UMEM Educational Pearls

Critically Ill Renal Transplant Patients

• Renal transplant patients are at high risk of critical illness from a variety of etiologies.
• Sepsis is the most common reason for critical illness and ICU admission.  
• Due to their immunosuppression, renal transplant patients are at risk of a multitude of infections.
• Notwithstanding, acute bacterial pyelonephritis of the transplant is the most frequent cuase of sepsis, followed by bacterial pneumonia.
• Be sure to consider these two etiologies when faced with a critically ill, septic renal transplant patient.

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Takeaways

---Early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of some complications from influenza.

---Early treatment of hospitalized adult influenza patients with oseltamivir has been reported to reduce death in some observational studies.

---Clinical benefit is greatest when antiviral treatment is administered within 48 hours of influenza illness onset.

Antiviral treatment is recommended for patients with confirmed or suspected influenza who:

---are hospitalized;

---have severe, complicated, or progressive illness; or

---are at higher risk for influenza complications. (See below for in-depth information)

Oral oseltamivir is the recommended antiviral for patients with severe, complicated, or progressive illness who are not hospitalized, and for hospitalized influenza patients.

Treatment:

Doses: Oseltamivir 75 mg twice daily

Renal Impairment Dosing

CrCl >60 mL/minute: No dosage adjustment necessary

CrCl >30 to 60 mL/minute: 30 mg twice daily

CrCl >10 to 30 mL/minute: 30 mg once daily

ESRD undergoing dialysis: 30 mg immediately and then 30 mg after every hemodialysis session

Duration of Treatment:

Recommended duration for antiviral treatment is 5 days for oral oseltamivir. Longer daily dosing can be considered for patients who remain severely ill after 5 days of treatment.

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Dyspnea in the Intubated Patient

• Dyspnea may occur in up to 50% of intubated patients and has been associated with prolonged mechanical ventilation.
• A number of assessment tools are available to detect dyspnea in the intubated patient.
• Regardless of the tool used, once dyspnea is diagnosed, consider the following;
  • When possible, reduce nonrespiratory stimuli of the respiratory drive (i.e., fever, acidosis, anemia)
  • Minimize respiratory impedance (i.e., bronchodilators, thoracentesis for pleural effusion)
  • Optimize ventilator settings (i.e., change modes if applicable, increase inspiratory flow, increase PEEP)
  • Pharmacologic treatment (i.e., opioids, benzodiazepines)

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The European Society of Intensive Care Medicine (ESICM) recently released a review with recommendations from an expert panel for the use of IV fluids in the resuscitation of patients with acute circulatory dysfunction, especially in settings where invasive monitoring methods and ultrasound may not be available.

Points made by the panel include: 

• Circulatory dysfunction should be identified not only by HR and BP, but by other indicators of poor perfusion: altered mentation, decreased urine output, and skin abnormalities (poor skin turgor, mottling, delayed capillary refill)

• The absence of arterial hypotension does not preclude hypovolemia

• The lack of an increase in MAP (especially in patients with decreased vascular tone) does not exclude positive response to IVF

• The purpose of IVF administration is to improve tissue perfusion by increasing cardiac output

• Fluid "loading" as the rapid administration of large volumes of fluid to treat overt hypovolemia, while a fluid "challenge" is a test of fluid responsiveness

• In elderly patients or those with arteriosclerosis or chronic arterial hypertension, a low pulse pressure (e.g. less than 40 mmHg) indicates that stroke volume is low. PP = SBP - DBP

Recommendations from the panel include:

• The early measurement of lactate to incorporate in the assessment of perfusion

• The use of crystalloids as initial resuscitation fluid (unless blood products are indicated)

• When overt hypovolemia is unclear, the use of a fluid challenge of 150-350mL IVF within 15 minutes to help assess fluid responsiveness

• Avoidance of using jugular venous distension alone as a guide for resuscitation

• Avoidance of using acute urine output response alone as a guide for resuscitation, as renal response to fluids can be delayed

• A recommendation against using CVP as a target for resuscitation; if CVP is being measured, a rapid increase with IVF should suggest poor fluid tolerance

• Individualizing fluid resuscitation to the patient's current presentation, underlying comorbidities, and response to fluids

Bottom Line: Utilize all the information you have about your patient to determine whether or not they require IVF, and reevaluate their physical and biochemical (lactate) response to fluids to ensure appropriate IVF administration and avoid volume overload. 

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Taking a double-dose of a single medication is presumed to be safe in most cases. However, there is limited data to support this assumption.

A retrospective study of the California Poison Control System was performed to assess adverse effects of taking double dose of a single medication. During a 10-year period, 876 cases of double-dose ingestion of single medication were identified.

Adverse effects were rare (12 cases). However, medication classes that were involved in severe adverse effects included: 

1. Propafenone: ventricular tachycardia and syncope
2. Beta blockers (BB): bradycardia and hypotension
3. Calcium channel blockers (CCB): bradycardia and hypotension
4. Bupropion: seizure 
5. Tramadol: ventricular tachycardia

Conclusion:

• Adverse effect from double dosing is rare.
• Cardiovascular collapse can occur with BB and CCB
• Seizure can occur with tramadol and bupropion.

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A previous pearl discussed medication-overuse headache (MOH).

MOH is also known as analgesic rebound headache, drug-induced headache or medication-misuse headache.

It is defined as headache… occurring on 15** or more days per month in a patient with a preexisting headache disorder who has been overusing one or more acute treatment drugs for headache with symptoms for three or more months.

The diagnosis is clinical, and requires a hx of chronic daily headache with analgesic use more than 2-3d per week.

The diagnosis of MOH is supported if headache frequency increases in response to increasing medication use, and/or improves when the overused medication is withdrawn.

The headache may improve transiently with analgesics and returns as the medication wears off. The clinical improvement after wash out is not rapid however, patients may undergo a period where their headaches will get worse. This period could last in the order of a few months in some cases.

The meds can be dc’d cold turkey or tapered depending on clinical scenario.

Greatest in middle aged persons. The prevalence rages from 1% to 2% with a 3:1 female to male ratio.

Migraine is the most common associated primary headache disorder.

** Each medication class has a specific threshold.

Triptans, ergot alkaloids, combination analgesics, or opioids on ten or more days per month constitute medication overuse.

Use of simple analgesics, including aspirin, acetaminophen and NSAIDS on 15 or more days per month constitutes medication overuse. 

Caffeine intake of more than 200mg per day increases the risk of MOH.

Consider MOH in patients in the appropriate clinical scenario as sometimes doing less is more!

Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis.  Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete.  Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes.  Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.

The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics.  The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed.  There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.

Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.

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Selective serotonin reuptake inhibitors are the most common anti-depressant used today. However, the use bupropion in adolescents is increasing due the belief that it has fewer side effects than TCAs.

Using the National Poison Data System (2013 – 2016), the adverse effects of bupropion were compared to TCA in adolescents (13 – 19 years old) with a history of overdose (self harm). 

Common clinical effects were:

TCA:  n=1496; Bupropion: n=2257

Conclusion:

Bupropion overdose results in significant adverse effects in overdose; however, death is relatively rare.

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• Lumbar punctures (LPs) are a common ED procedure with variable reported success rates.
• A recent systematic review and meta-analysis looked at 12 studies comprising 957 adult and pediatric patients comparing pre-procedural ultrasound-assisted LPs with traditional landmark-based technique.
  • Some studies utilized ultrasound-assistance in all LPs, others selected patients who were anticipated to be difficult LPs.
  • No studies assessed dynamic ultrasound-guided LPs.
• Overall, ultrasound-assisted LP was 90.0% successful compared with landmark-based LP that was 81.4% successful (OR 2.22, 95% CI = 1.03 - 4.77).
• Ultrasound-assisted LP was also associated with reduced rate of traumatic LPs, shorter time to successful LP, and reduced patient pain scores.

Bottom Line: Consider using pre-procedural ultrasound-assistance for all lumbar punctures.

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Noninvasive Ventilation in De-Novo Respiratory Failure

• Noninvasive ventilation (NIV) is a primary therapy for patients with acute hypercapnic respiratory failure, especially those with an acute COPD exacerbation.
• Notwithstanding its benefits in COPD and acute cardiogenic pulmonary edema, NIV should be used cautiously in patients with "de-novo" respiratory failure.
• Many patients with de-novo respiratory failure will meet criteria for ARDS and have a high rate of intubation (30% - 60%).
• The use of NIV with delayed intubation in this patient population has been associated with increased mortality. 

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Retrospective chart review at a headache clinic seeing adolescent concussion patients

70.1% met criteria for probable medication-overuse headache

Once culprit over the counter medications (NSAIDs, acetaminophen) were discontinued,

68.5% of patients reported return to their preinjury headache status

Take home:  Excessive use of OTC analgesics post concussion may contribute to chronic post-traumatic headaches

If you suspect medication overuse, consider analgesic detoxification

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Hyperoxia has been repeatedly demonstrated to be detrimental in a variety of patients, including those with myocardial infarction, cardiac arrest, stroke, traumatic brain injury, and requiring mechanical ventilation,^1-4 and the data that hyperoxia is harmful continues to mount:

• Systematic review and meta-analysis of 16,000 patients admitted to hospital with sepsis, trauma, MI, stroke, emergency surgery, cardiac arrest: liberal oxygenation strategy (supplemental O2 for average SpO2 96%, range 94-100%) associated with increased in-hospital and 30-day mortality compared to conservative strategy.⁵

• ED patients requiring mechanical ventilation admitted to ICU: hyperoxia defined as PaO@ >120mmHg. Patients with hyperoxia in the ED had higher mortality than not only normoxic but hypoxic patients (30% v 19% v 13% respectively), and longer vent days and ICU/hospital LOS.⁶

• ICU patients, majority respiratory failure, 60% requiring mechanical ventilation; hyperoxia defined as PaO2 >100mmHg. Just ONE episode of hyperoxia an independent risk factor for ICU mortality (OR 3.80, 95% CI 1.08-16.01, p=0.047).⁷

Bottom Line: Avoid hyperoxia in your ED patients, both relatively stable and critically ill. Remove or turn down supplemental O2 added by well-meaning pre-hospital providers and nurses, and wean down ventilator settings (often FiO2). A target SpO2 of >92% (>88% in COPD patients) or PaO2 >55-60 is reasonable in the majority of patients.⁸

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Providing naloxone to patients at risk for opioid overdose is now standard of care. A retrospective study evaluated the rate of naloxone obtainment after standardizing the process for prescribing naloxone in the emergency department and dispensing from the hospital outpatient pharmacy. 

55 patients were prescribed naloxone.  Demographics: mean age 48 years old, 75% male, 40% primary diagnosis of heroin diagnosis, 45.5% were prescribed other prescriptions.

Outcomes:

• 25.5% brought the prescription to the pharmacy
• 18.2% completed education and obtained naloxone
• 10% higher rate of success if patient had multiple prescriptions to fill

Barriers identified included lack of ED dispensing program, cost of medication, even though cost is minimal and can be waived, and likely multifactorial reasons why patients did not present to pharmacy as instructed.

Take Home Points:

• In this complex and challenging patient population, naloxone should be provided
• Utilize UMMC ED Meds to Beds technicians 1130-1900 M-F to prevent patients from having to travel to pharmacy post-ED visit as this can be a barrier.  The pharmacy technician
• Prescribe AED To-Go naloxone after hours to improve access to naloxone

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• No matter what the school nurse says, only a temperature >/= 100.4 F or 38 C is a fever.
• Routine use of rectal and oral routes to measure temperature are not required to document a fever in children.
• Use of electronic thermometers in the axilla is acceptable even in children under 5 years
• Forehead chemical thermometers are unreliable.
• Reported parental perception of fever should be considered valid and taken seriously.
• Measure heart rate, respiratory rate, and capillary refill as part of the assessment of a child with fever.
• Heart rate typically increases by 10, and respiratory rate increases by 7 for each 1 C temperature increase.
• If the heart rate or capillary refill is abnormal in a child with fever, measure blood pressure.
• Do not use height of temperature to identify serious illness.
• Do not use duration of fever to predict serious illness.
• Tepid sponging/bathing, underessing, and over-wrapping are not recommended in fever.
• Do not give acetaminophen and ibuprofen simultaneously.

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Alcohol withdrawal syndrome is frequently treated with benzodiazepines following CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol scale). There are other medications that are used as either second line or as adjunctive agents along with benzodiazepines. A retrospective study compared the clinical outcomes between phenobarbital vs. benzodiazepines-based CIWA-Ar protocol to treat AWS. 

The primary was ICU length of stay (LOS); secondary outcome were hospital LOS, intubation, and use of adjunctive pharmacotherapy.

Study sample: 60 received phenobarbital and 60 received lorazepam per CIWA-Ar.

Phenobarbital protocol:

• Active DT: 260 mg IV x 1 dose -> 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
• History of DT: 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
• No history of DT: 64.8 mg PO TID x 6 dose -> 32.4 mg PO TID x 6 doses.

Results

Conclusion

Phenobarbital therapy appears to be a promising alternative therapy for AWS. However, additional studies are needed prior to adapting phenobarbital as first line agent for AWS management. 

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Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:

C.N.: cranial nerve

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A few (out of 10) tips for the care of sick patients with liver failure:

• Use of albumin is indicated to improve outcomes in spontaneous bacterial peritonitis (SBP), large-volume paracentesis, and hepatorenal syndrome (HRS).

• Norepinephrine remains the vasopressor of choice for nonhemorrhagic shock. Use vasopressin or terlipressin (outside the U.S.) in AKI due to HRS to maintain a target MAP and for splanchnic vasoconstriction.

• INR does not correctly reflect coagulation performance. Platelet count and fibrinogen are the best predictors of bleeding, and thromboelastography (via TEG/ROTEM) can reduce blood products administered for hemorrhage without affecting mortality.

• If a nasogastric tube is indicated (administration of lactulose, decompression of SBO, etcetera), presence of [non-recently banded] esophageal varices is not a contraindication.

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Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old.  X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies.  This study aimed to find a way to decrease radiation exposure by using a metal detector.

19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study.  All proximal esophageal coins were detected by the metal detector.  5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.

Bottom line: A metal detector may detect proximal esophageal coins.  This may have a role in decreasing repeat x-rays.

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• The Canadian C-Spine Rule (CCR) has been shown to decrease the use of cervical spine imaging in low-risk trauma patients.
• While developed for use by physicians, CCR has also been validated in ED triage nurses with moderate interrater reliability (kappa 0.78) by Stiell et al. in 2010.
• Stiell’s group has since implemented the use of CCR by ED triage nurses at 9 teaching hospitals in Ontario with a combined annual volume of approximately 670,000 ED visits.
• 180 certified nurses evaluated 1408 patients.
  • 806 (57.2%) arrived with c-spine immobilization.
  • 602 (42.8%) had neck pain but no immobilization.
• Overall, nurses removed immobilization in 331 (41.4%) patients and applied immobilization in 203 (14.4%) patients.
• Diagnostic imaging was performed in 612 (43.4%) patients and found 16 (1.1%) clinically important and 3 (0.6%) clinically unimportant injuries.
• There were no missed c-spine injuries to the knowledge of the authors as the study hospitals were closely connected with the regional spine centers.
• Time from nursing assessment to discharge decreased by 26.0% (3.4h vs. 4.6h)

Bottom Line: ED triage nurses can safely use the Canadian C-Spine Rule.  This approach can improve patient care and decrease length of stay in the ED.

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Identifying Critically Ill Cancer Patients in the ED

• Immunosuppressed patients with malignancy are at high risk of complications and rapid decompensation.
• Select pearls in identifying ED patients with cancer that are at high risk of critical illness include:
  • Patients with profound neutropenia (< 100/mm³) are at high risk for fungal infections (i.e., aspergillosis)
  • Hypoxemia that requires oxygen is a predictor of later ICU admission.
  • Patients with bilateral infiltrates on CXR are at high risk of decompensation. Consider ICU admission.
  • Patients with promyelocytic leukemias are at high risk of DIC. Patients with this complication should be admitted to the ICU.

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