Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Why does this matter?
SMART found that balanced crystalloid reduced major adverse kidney events, and the benefit appeared even greater in the subgroup with sepsis. For the first 7 months of the SMART study, the choice of IV fluid was not made until after the patient was in the ICU. But for the last 15 months of the study, the choice of fluid was made in the ED. Does an earlier start of balanced crystalloid in the ED impact mortality among critically ill septic patients?

A SMART fluid choice
This was a secondary analysis of SMART data comparing volume resuscitation with normal saline vs lactated Ringer’s or Plasmalyte (balanced crystalloid) among the subgroup of SMART patients with sepsis. For the 367 patients with the IV fluid choice after ICU arrival (late fluid), there was no mortality benefit with balanced fluid: 33.1% balanced vs. 32.9% saline; OR 1.14 (95%CI 0.70-1.88). However, when the fluid choice was started in the ED (early fluid) there was a mortality benefit with balanced fluid: 24.9% balanced vs. 30.6% saline; OR 0.68 (95%CI, 0.52-0.89). Bear in mind, this was not the primary outcome of the original study and only includes the subgroup of patients with sepsis admitted to the MICU. Nevertheless, it is interesting, noteworthy, and confirms my current practice.

Source
Effect of Early Balanced Crystalloids before ICU Admission on Sepsis Outcomes. Chest. 2020 Aug 31:S0012-3692(20)34295-1. doi: 10.1016/j.chest.2020.08.2068. Online ahead of print.

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#2: ACEP Opioid Policy Statement

Spoon Feed
This is an ACEP Clinical Policy statement to address four key questions about opioid use in the ED.

Why does this matter?
Drug related deaths are now more common than deaths due to motor vehicle crashes. Not only is addiction and overdose a problem, these medications have other side effects, such as nausea, constipation, and increased fall risk.

Addressing pain points

Here are the four questions addressed by this clinical policy.

1) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies?

• Level B recommendations: “When possible, treat opioid withdrawal in the ED with buprenorphine or methadone as a more effective option compared with nonopioid-based management strategies such as the combination of alpha2-adrenergic agonists and antiemetics.” Level C recommendations. “Preferentially treat opioid withdrawal in the ED with buprenorphine rather than methadone.”

• Comment: Use of buprenorphine in a patient who does not yet have withdrawal (COWS <8) may precipitate withdrawal. Methadone, with its long half life, may lead to increased risk of respiratory depression if given in the ED and a patient resumes use of other opioids; it also prolongs the QT interval. Prescribing buprenorphine requires special training and the DEA X-waiver.

2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms?

• Level C recommendations. “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the ED. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.”

• Comment: Emergency physicians are not the main drivers of prescriptions leading to subsequent abuse, but 1-5% of patients prescribed opioids in the ED may have prolonged use, depending on how much was prescribed at the initial visit. There are few painful conditions for which an opioid alternative is not as good, if not better, for pain control. Lest we go too far, there is a place for opioids for severely painful conditions, i.e. metastatic cancer, severe injuries, etc.

3) In adult patients with an acute exacerbation of non-cancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms?

• Level C recommendations. “Do not routinely prescribe opioids to treat an acute exacerbation of non-cancer chronic pain for patients discharged from the ED. Non-opioid analgesic therapies (non-pharmacologic and pharmacologic) should be used preferentially. For cases in which opioid medications are deemed appropriate, prescribe the lowest indicated dose of a short-acting opioid for the shortest time that is feasible.”

• Comment: This is an easy area for us to improve – no opioid prescriptions for chronic pain flare-ups…period.

4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits?

• Level C recommendations. “Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the ED (Consensus recommendation).”

• Comment: Overdose deaths are greater when opioids are combined with benzodiazepines or other sedatives. Just avoid this. Muscle relaxers are minimally effective, if at all, anyway.

Source
Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Opioids. Ann Emerg Med. 2020 Sep;76(3):e13-e39. doi: 10.1016/j.annemergmed.2020.06.049.

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Why does this matter?
Most of us are aware that several drugs and drug classes may prolong the QT interval and predispose a patient to torsades de pointes. But did you know multiple medications are also associated with atrial fibrillation, atrial tachycardia, bradyarrhythmias, atrioventricular nodal reentrant tachycardia (AVNRT), monomorphic ventricular tachycardia (VT), and unmasking Brugada syndrome?

Careful with that Rx pad…
For each arrhythmia, there are numerous drugs that may cause it. I can’t list them all. It is important for you to pull the full text of this article and read through it for yourself. But I will try to list the most commonly encountered meds in the ED for each drug-induced rhythm disturbance.

Bradyarrhythmias

• Propofol

• Physostigmine

• Adenosine, amiodarone, sotalol

• Citalopram, fluoxetine

• Clonidine, beta blockers, verapamil, diltiazem

• Digoxin

• Dipyridamole

Atrial fibrillation/flutter; a similar list causes atrial tachycardia as well

• Adenosine, amiodarone

• Multiple antineoplastic agents: tyrosine kinase inhibitors, anthracyclines, alkylating agents, HER2 receptor blockers, 5FU, microtubule agents

• Fluoxetine

• Ondansetron

• Diclofenac, COX2 inhibitors, corticosteroids

• Prochlorperazine, olanzapine

• Bisphophonates

• Albuterol, terbutaline

• Cannabis

• Dobutamine, dopamine, epinephrine

• Alcohol

• Physostigmine

• Amphetamines

• Milrinone

• Morphine

• Sildenafil

• Caffeine (say it isn’t so…)

• Isoproterenol

AVNRT

• Phenylpropanolamine

• Clozapine, fluoxetine

• Albuterol

• Dobutamine

• Methylprednisolone

• Furosemide

• Caffeine (that explains a lot…), methylphenidate

Monomorphic VT

• Bupivacaine

• Adenosine, amiodarone, propafenone, procainamide

• 5FU, anthracyclines, immune checkpoint inhibitors (myocarditis)

• Bupropion, citalopram, imipramine, venlafaxine, trazodone, lithium

• Dipyridamole

• Chlopromazine

• Digoxin, dobutamine

• Terbutaline

• Methamphetamine

Brugada

• Flecainide, propafenone, procainamide

• Tricyclics

• Bupivacaine, propofol

• Alcohol, lithium, oxcarbazepine

Torsades de pointes (via prolonged QT interval)

• Propofol

• Amiodarone, flecainide, ibutilide, procainamide

• Azithromycin, ciprofloxacin, levofloxacin

• Citalopram

• Droperidol (although you may want to read this…), ondansetron

• Fluconazole, pentamidine

• Hydroxychloroquine

• Haloperidol

• Methadone

Again, this is not an exhaustive list. It’s probably best for you to review the full article. I listed the ones you will encounter most often in clinical practice and in the ED. You will see some recurrent offenders on several of these lists. Be especially wary of these agents. Not only should you be careful what you prescribe and to whom; be sure to also think in reverse – if a patient presents with an arrhythmia, check the med list.

Source
Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association. Circulation. 2020 Sep 15:CIR0000000000000905. doi: 10.1161/CIR.0000000000000905. Online ahead of print.

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