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: Vancomycin/Piperacillin-Tazobactam and AKI

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The combination of vancomycin plus piperacillin-tazobactam (VPT) was associated with increased risk of acute kidney injury (AKI) compared to either drug as monotherapy or other vancomycin/β-lactam combinations, NNH = 11.

Why does this matter?
The combination of VPT is common in sepsis patients.  Several papers have been published that raise concern that this combo may increase risk of AKI.  This is a synthesis of some of those papers.

The sepsis combo
This was a meta-analysis of papers studying VPT and AKI and included 15 published studies, 17 abstracts, with a total of nearly 25,000 patients.  They found that the VPT combo was associated with increased risk of AKI compared with vancomycin alone, piperacillin-tazobactam alone, or vancomycin combined with cefepime or a carbapenem, overall NNH = 11.  Many studies defined AKI based on rise in creatinine, which may have been transient.  However, the authors noted that, “even transient changes in renal function are associated with worse outcomes.”  So, what are we to do?  Protocols with alternative regimens to limit the frequency of VPT use is one step; cutting the duration of this therapy via deescalation is another.

Source
Are Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at Higher Risk for Acute Renal Injury?  Ann Emerg Med. 2018 Oct;72(4):467-469. doi: 10.1016/j.annemergmed.2018.06.004. Epub 2018 Jul 27.

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#2: Inhaled Tranexamic Acid for Hemoptysis?

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For patients with hemoptysis, inhaled tranexamic acid was associated with significantly reduced expectorated blood volume, hospital length of stay, need for invasive interventions, and hemoptysis recurrence rate at one year. Patients with inhaled tranexamic acid also had higher rate of hemoptysis resolution within 5 days.

Why does this matter?
Hemoptysis, defined as the expectoration of blood, has a broad differential and can range from simple blood streaked sputum to life-threatening massive hemoptysis. Management of hemoptysis consists of interventional procedures to stop hemorrhage along with identifying and treating the specific underlying cause. However, there are few other effective medical therapies for undifferentiated hemoptysis besides supportive care. Intravenous tranexamic acid (TXA) has shown promise at reducing surgical blood loss, decreasing abnormal uterine bleeding, and controlling acute hemorrhage in trauma. Therefore, could inhaled TXA be a potential medical therapy for hemoptysis?

TXA in hemoptysis: The results may take your breath away…
This was a single center, prospective, double-blind, randomized, placebo-controlled trial of 47 adults with hemoptysis comparing nebulized TXA 500 mg/5 ml vs nebulized normal saline 5 ml as the placebo control, given 3 times a day up to 5 days from admission. Patients with massive hemoptysis (expectorated blood > 200 ml/24 hrs), respiratory or hemodynamic compromise, pregnancy, renal or hepatic failure, coagulopathy, or TXA hypersensitivity were excluded.

TXA compared to placebo was associated with an improved rate of hemoptysis resolution within 5 days (96% vs 50%, p<0.0005), reduced length of stay (5.7 vs 7.8 days, p=0.046), reduced rate of invasive procedures such as bronchoscopy or angiographic embolization (0% vs 18.2%, p=0.041), and reduced recurrence of hemoptysis at 1 year (4% vs 22.7%, p=0.0092). No side effects were noted.

This was a small single center study with several limitations and a large proportion of patients excluded that we normally care for in the Emergency Department, including those with massive hemoptysis. However, the results are compelling that nebulized tranexamic acid may be a safe and effective treatment option for patients with hemoptysis. With little downside and few other proven medical therapies for hemoptysis, nebulized TXA could be a useful adjunct to add to your mental tool belt.

Source
Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026. [Epub ahead of print]

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#3: POCUS for LP – Watch Videos

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With the combined weight of twelve RCTs, ultrasound-guided LP was shown to be superior to landmark-guided LP in multiple ways.

Why does this matter?
Point-of-care ultrasound (u/s) is used for many ED procedures, such as central line placement, abscess drainage, paracentesis, thoracentesis, and more. Numerous studies have been published about its use for LP. This is a compilation of those with the highest quality.

Someone needs to learn this (he says sheepishly)
This was a meta-analysis of 12 RCTs, 957 total patients, that found the primary outcome of success was 90% with ultrasound guidance and 81.4% when using landmarks only; risk difference 8.9%, NNT = 11. Other secondary outcomes also showed improvement with u/s, including half the number of traumatic taps, 1-minute shorter procedure time, fewer passes with the needle, and reduction in pain by almost half. When adult and pediatric studies were separated and pooled, there remained a trend for each toward improved overall success with u/s, but the results were no longer statistically significant. However, statistical significance remained for the other secondary outcomes when adult-only or pediatric-only studies were pooled.

Another Spoonful

Source
Ultrasound-Assisted Lumbar Punctures: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2018 Aug 21. doi: 10.1111/acem.13558. [Epub ahead of print]

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