Journal Feed Weekly Wrap-Up
- Oct 17th, 2020
- Clay Smith
In novice interns, ultrasound guidance for radial arterial line placement improved first-pass success in addition to accomplishing cannulation with fewer attempts and in less time over a landmark-based approach.
Why does this matter?
Often when we really need an arterial line, the radial pulse is hard to palpate due to hypotension. Placement by palpation is technically challenging and time consuming. Yet, arterial line placement is a common ED procedure. Is there a way to increase success, reduce complications, and improve efficiency when placing arterial lines? Ultrasound for the win!
Palpate the ultrasound, not the pulse
This was a single-center, prospective RCT comparing ultrasound guided (USG) vs landmark guided (LMG) radial arterial line placement. PGY-1 emergency medicine interns with <15 previous attempts were randomized, with a primary outcome of overall success and secondary outcomes of first-pass success, attempt number, time to completion and complications. Overall success in USG and first-pass success with ultrasound were 100% and 75%, respectively. LMG was 15% for overall success and 0% for first-pass success. Time to cannulation (264 sec vs 524 sec) and overall number of attempts (1.3 vs 2.95) were about half in the USG compared to LMG as well. There was an isolated hematoma as a complication in the LMG group, with no reported complications in the USG group. For the 17 failed lines using LMG, all crossed over to USG and were then successful.
In addition to being a small study of 40 patients, there are several other limitations mentioned in the paper. This was a single-center, ultrasound division-run trial at a Level-1 medical center, which is not directly representative of the broader EM community, possibly biasing toward ultrasound use. This also focused on novice interns who received 4 hours of ultrasound-guided cannulation didactics rather than all levels of providers and experience levels. Nonetheless, the data here supports ultrasound use as being more successful and efficient and causing less harm, making a strong case for ultrasound as the preferred method of placement of radial arterial lines.
Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial. J Emerg Med. 2020 Sep 8:S0736-4679(20)30711-3. doi: 10.1016/j.jemermed.2020.07.029. Online ahead of print.
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Use of steroids for critically ill patients with COVID-19 significantly reduced 28-day mortality.
Why does this matter?
RECOVERY showed likely benefit of dexamethasone in ill patients with COVID-19. In addition, 55 corticosteroid trials for COVID have been registered on ClinicalTrials.gov (most of which suspended enrollment after RECOVERY). So, what’s the consensus?
Corticosteroids look like a winner for sick COVID patients.
This was a very rapidly produced meta-analysis of 7 RCTs that included 1,703 patients with critical illness due to COVID-19. Six of seven studies were considered low risk for bias. When the studies were combined, there was a beneficial effect on the primary outcome, 28-day mortality, in patients who received steroids vs placebo; summary odds ratio 0.66 (95%CI 0.53-0.82). There was no increase in adverse events. The subgroups were not large enough to detect a difference among steroid types, whether dexamethasone, hydrocortisone, or methylprednisolone. Doses of dexamethasone ranged from 6mg to 20mg daily in the three studies; hydrocortisone was a 200mg total daily dose in the three studies; the single methylprednisolone study was 40mg twice a day. It seems reasonable, since RECOVERY made up 57% of the weight of this meta-analysis, to go with dexamethasone at a lower daily dose.
Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA. 2020 Sep 2. doi: 10.1001/jama.2020.17023. Online ahead of print.
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ED boarding of critically ill patients is common and is associated with worse clinical outcomes: increased duration of mechanical ventilation, increased probability of poor neurologic outcome, longer ICU length of stay, and higher in-hospital mortality. This a systemic problem with no easy fix.
Why does this matter?
Although definitions vary, ED boarding is both harmful to patients and widespread. There has been an 80% increase in ED visits for critically ill patients (2006-2014), with a minimal growth in ED capacity or inpatient ICU bed space. You will be taking care of a critically ill patient in the ED at some point, and understanding the causes, limitations, and mitigation efforts will help patient care.
SORRY, NO VACANCY
A task force set out to answer three questions related to boarding of critically ill patients in United States emergency departments. 18 retrospective and prospective studies were used to collect the information needed.
What is the frequency of critically ill patients boarding in the ED?
There is no accepted universal definition of ED boarding, and estimates for ED boarding incidence range from 2.1 – 87.6%. Some use time metrics (2,4, or 6 hours) while others use total numbers of hours an intubated patient spends in the ED.
From 2006 – 2014 ED visits for critically ill patients increased by 80%, and intubated patients in the ED increased by 16%.
Over 250,000 patients a year receive mechanical ventilation in the ED with a median LOS greater than 3 hours.
What are the outcomes associated with critically ill patients boarding in the ED?
ED boarding is associated with increased duration of mechanical ventilation, longer ICU length of stay, higher mortality, and four-fold increase in probability of poor neurologic recovery in stroke patients.
ED boarding also lends itself toward low-quality process-related care of the critically ill, including post-intubation elements, delays in home medication initiation, fluids, antibiotics, and disease-specific protocolized care.
ED boarding affects the care of other ED patients secondary to resource allocation.
There is particular concern with patients who are declined ICU admission and then must be “stabilized” to meet the requirements for a floor bed. This leads to substantial increases in boarding times (11.7 vs 4.2 hours).
What are some mitigation strategies to decrease the impact of critically ill patients boarding in the ED?
ED solutions: Targeted interventions to improve pain and agitation management, vent management, more frequent hemodynamic assessments, infection prevention and targeted resource utilization can be used to improve both critically ill and general ED patient disposition and care. Using models to predict when a surge may happen based on waiting room status, hospital capacity, and retrospective review of trends may help plan for ED critical care boarding.
Hospital Solutions: ICU alert teams have been deployed to the ED to take care of boarding ICU patients. Good interdepartmental collaboration to help move patients laterally from one ICU to another in the same institution, and priority placement of ICU patients being transferred to the ward (as opposed to new ward patients from the ED getting those beds) can help. Other ways to offload hospital capacity include “discharge waiting rooms” for low acuity patients who have been discharged and are waiting on pharmacy/paperwork/rides etc. Stepdown units can play a role in allowing sick patients who are not crashing to receive the higher level of care necessary while keeping ICU beds open.
ED Resuscitative Care Units: Several centers across the U.S. use critical care units in the ED to directly address critical patients boarding. Observational data from one center that employs this model showed 15.4% reduction in risk-adjusted 30-day mortality among all ED patients, and reduction in hospital and 24-hour mortality. ICU admission fell 12.9%, and ICU length of stays less than 24 hours fell by 37.1%. Patients overall received ICU-level care faster. Comparative studies from the other institutions practicing this have yet to be published.
A key statement was: “ED boarding reflects symptoms of a systemic healthcare problem with multiple downstream effects; it is not simply a failure of ED operations.”
While this study did not directly address the type of centers most effected, working at a large tertiary and academic referral center I often feel the pressures and effects of ED boarding, and I am sure that I’m not alone. This will take a massive overhaul of our healthcare system to fix. But understanding and defining the problem is an important first step.
Boarding of Critically Ill Patients in the Emergency Department. Crit Care Med. 2020 Aug;48(8):1180-1187. doi: 10.1097/CCM.0000000000004385.
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