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. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

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#1: High-Flow vs. Conventional Oxygen for Severe COVID-19

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Patients suffering from severe COVID-19 who are treated with high-flow oxygen nasal cannula, compared with those treated with conventional supplemental oxygen, have decreased need for mechanical ventilation and more rapid clinical recovery.

Why does this matter?
COVID-19 appears to be here to stay, at least for the foreseeable future. This means it’s time to be experts in treatment options. High-flow nasal cannula is comfortable for patients, low-risk, and provides an alternative method to deliver supplemental oxygen when compared with traditional protocols. It has become much more popular during the pandemic, and we should be familiar with evidence to support it.

High flow is the way to go
This is a randomized, open-label clinical trial performed in Emergency Departments and ICUs in which patients suffering from COVID-19 with severe features (PaO2/FIO2 < 200) were randomized to high-flow nasal cannula with heated humidified oxygen or conventional oxygen supplementation using nasal cannula or mask. Patients randomized to high-flow oxygen therapy were less likely to undergo intubation within 28 days (34.3% vs. 51% p = 0.03) and more likely to sustain clinical recovery within 28 days (77.8% vs. 71%, p = 0.047). However, there was no statistical significance in mortality between the two treatment groups.

Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2161-2171. doi: 10.1001/jama.2021.20714.

#2: Puff the Magic Ketamine Neb

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Nebulized ketamine may be the newest way to treat both acute and chronic pain in the Emergency Department.

Why does this matter?
The management of pain is a constant battle in the ED, and the provider has many factors to take into account when selecting analgesic medication. With nebulized ketamine, the provider may be able to achieve clinically meaningful reduction in pain while decreasing side effects seen with intravenous ketamine administration, avoiding the unpleasant intranasal route, and bypassing opioids all together.

All you need is Neb
This was a randomized, double-blind superiority trial comparing 3 doses (0.75mg/kg, 1mg/kg, 1.5mg/kg) of breath-actuated nebulized ketamine for the management of acute and chronic pain. Quick background: breath-actuated nebulized ketamine has 20-40% of the bioavailability as compared to IV route with a duration of 20-40 minutes.

The primary outcome was difference in pain scores measured at 30 minutes. And while all doses demonstrated clinically significant pain reduction, there was no additional benefit to the higher doses. To add context to their secondary outcomes (adverse events and need for rescue analgesia), the authors compared these data to their prior studies on IV ketamine and morphine (things that we in the ED are much more comfortable with). Clinical pain reductions were on par with the degree of pain relief seen with IV ketamine and morphine. Adding even more to the appeal, the authors point to a reduction in adverse effects and less need for rescue analgesia.

While several limitations exist to the broad application of this route of administration of ketamine – both with availability of the equipment and need for patient education – the results are pretty groovy.

Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med. 2021 Dec;78(6):779-787. doi: 10.1016/j.annemergmed.2021.04.031. Epub 2021 Jul 3.

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The CODA trial initially found antibiotic treatment was noninferior to surgery for acute appendicitis at 30 days. In this follow up letter on long-term outcomes (up to 4 years), the incidence of appendectomy in the antibiotic group was higher than pooled results from prior trials.

Why does this matter?
The Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial (CODA) trial showed promise for antibiotics compared to appendectomy for short-term outcomes in patients with appendicitis. How did these patients do down the road?

Pills vs The Knife
Follow-up data showed 40% of patients who were initially treated in the antibiotic group had subsequent appendectomy at year 1; 46% at year 2; 49% at years 3 and 4. Appendectomy was more common among patients who had an appendicolith initially, though this greater risk seemed to dissipate over time. Authors also noted that by 2 years, 14% of patients in the antibiotic group required another course of antibiotics and subsequently 66% of those patients underwent appendectomy. This follow-up data is limited by the fact that many patients were lost to follow-up and authors were only able to collect data for 57% at year 2, 10% at year 3 and 5% at year 4.  Although this update on long-term outcomes isn’t that encouraging, antibiotic treatment remains an option, and this provides us additional data to discuss with our patients when utilizing shared decision-making regarding treatment for appendicitis.

Antibiotics versus Appendectomy for Acute Appendicitis – Longer-Term Outcomes. N Engl J Med. 2021 Dec 16;385(25):2395-2397. doi: 10.1056/NEJMc2116018. Epub 2021 Oct 25.

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