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: Permissive Hypotension in Elderly – Is a MAP 60-65 mm Hg Safe?

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It was safe to allow older patients with vasodilatory shock to have a lower target MAP of 60-65 mm Hg but not clearly superior to usual care.

Why does this matter?
Surviving Sepsis 2012 recommended a MAP target of 65 mm Hg, in general, and a higher target in elderly patients and those with chronic hypertension or coronary artery disease. Yet, SEPSISPAM (awesome study name!) and the OVATION pilot study seemed to signal this could lead to higher mortality in the elderly. Does allowing permissive hypotension in patients ≥65 years and only using vasopressors to maintain a MAP target of 60-65 mm Hg vs usual care improve 90-day mortality?

How low can you go…
This was a RCT, the 65 Trial, with 2,463 patients ≥65 years who were randomized into well matched, unblinded groups receiving usual care or permissive hypotension, with a lower MAP target of 60-65 mm Hg. There was no difference in 90-day mortality, which was the primary outcome: 41% permissive hypotension vs 43.8% usual care; difference -2.85% (95%CI -6.75 to 1.05). There was a lower total dose and less time on vasopressors in the permissive hypotension group. Serious adverse events, like renal failure or SVT, were similar among the groups. Counterintuitively, the subgroup with chronic hypertension was found to have statistically significant improvement in mortality with a permissive hypotension approach; but with no statistical correction for multiple comparisons, this may have been due to chance. It is unlikely this approach would cause harm. What I take home is that permissive hypotension in elderly patients who need vasopressors for shock appears safe and may even benefit select patients.

Source
Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA. 2020 Feb 12. doi: 10.1001/jama.2020.0930. [Epub ahead of print]

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#2: Toddler’s Fracture – CAM Walker Boot, Cast, or Nothing?

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This study was inconclusive, but provides assurance that treating children with confirmed or suspected toddler’s fracture (TF) in a controlled ankle motion (CAM) walker boot is safe and equally effective compared to casting.

Why does this matter?
Traditional treatment of a TF, or suspected TF, is an above the knee (AK) cast, but this is not often done in practice. The largest study of TF showed that a CAM walker boot is adequate and allows earlier weight bearing. All kids had good healing and return to weight-bearing at 4 weeks regardless of treatment modality. Do we need to do anything for TF?

That’s what I’m talkin’ a boot!
Six articles were found, 5 retrospective studies and one survey. Most were single-center chart reviews. The authors could not make conclusive recommendations that non-immobilization was safe based on this information. They did note that a, “majority of the studies suggest that TF can be managed conservatively with no initial immobilization or CAM boot.” It is important to note that casting is not benign. Skin breakdown was common in children who were immobilized in a cast; my best estimate based on these data was 3-26%. Although this study cannot provide conclusive management recommendations, when all these articles are considered together, I feel affirmed in my current practice, which is to place confirmed or suspected TFs in a CAM walker boot.

Source
Management of Toddler’s Fractures: A Systematic Review. Pediatr Emerg Care. 2020 Jan 20. doi: 10.1097/PEC.0000000000002005. [Epub ahead of print]

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Spoon Feed
Topical lidocaine was not shown to improve oral intake but did relieve pain in children with oral ulcers.

Why does this matter?
We often prescribe topical viscous lidocaine for children with gingivostomatitis or hand, foot, and mouth. The thought is it will relieve pain and allow them to orally hydrate. But does it actually help?

Mouth sores are a pain…
This was a brief systematic review of two RCTs on topical lidocaine for oral ulcers. One found no difference in short term oral fluid intake but did not measure pain scores. The other did not measure oral fluid intake but found improved pain scores with lidocaine. Both included children from 6 months to 8 years. I have a few thoughts. First, I think pain relief alone is a good enough indication to use this. I am surprised oral intake wasn’t better. It may have been that the short-term target goals were too ambitious in the included study. Remember, lidocaine may be toxic, with risks of seizure and even cardiac arrest reported. I usually ask parents if the child is able to brush teeth and spit the toothpaste out reliably. If so, I will use swish and spit. If not, I won’t. In very young children, lidocaine can be applied with a cotton swab. Bear in mind, repeated high dose mucosal exposure may still result in systemic absorption and toxicity, even if not swallowed. Make sure parents understand that it must be used under supervision, every 3-4 hours or so. The maximum dose should not exceed 4.5mg/kg/dose. That might sound like a lot, but a 4% topical concentration of lidocaine means 4000mg/100mL; 40mg per 1mL; 200mg/5mL. That is means in a 20kg child, the max dose of 4% is just 2.25mL. Be careful. I am on board with using this treatment. Sometimes it works like magic.

Source
BET 2: Does topical lidocaine improve oral intake in children with painful mouth ulcers? Emerg Med J. 2020 Feb;37(2):113-114. doi: 10.1136/emermed-2019-209390.3.

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