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. 
Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: CODA RCT – Antibiotics or Surgery for Appendicitis?

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Antibiotic treatment vs appendectomy for appendicitis had non-inferior 30-day quality of life scores, but need for subsequent surgery and complications were greater in the antibiotic group, especially in patients with an appendicolith.

Why does this matter?
Several studies have suggested antibiotic therapy for appendicitis is a viable option. I have had my doubts. A surgery journal found operative treatment was better. A pediatric journal found non-operative treatment was an option. The CODA collaborative thought there was clinical equipoise and did this RCT.

CODA – the ending is not what we want
This was a non-blinded, non-inferiority, multicenter randomized trial of 1,552 adults with image-confirmed appendicitis. There was non-inferiority for the primary outcome of quality of life score at 30 days. Scores were nearly identical. However, in patients treated with antibiotics, 29% had undergone appendectomy by 90 days (including 25% of those who did not have an appendicolith). Complications, such as infection, need for a drain, or antibiotic-related reactions were more common in the antibiotic group, mainly driven by the subgroup of patients with an appendicolith. That’s not good. This meant more repeat ED visits, more CT scans, more time, and possibly more money. In other words, too many patients in the antibiotic group had a dissonant coda.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Oct 5. doi: 10.1056/NEJMoa2014320. Online ahead of print.

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#2: Seat Belt Sign – How Good Is CT for Intra-abdominal Injury?

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CT scan of the abdomen/pelvis had 100% sensitivity (95%CI 92.5-100) for detecting intra-abdominal injury in trauma patients with abdominal seat belt sign (ASBS). Both abrasions or ecchymoses over the seat belt area were associated with increased risk of intra-abdominal injury.

Why does this matter?
If you work at a trauma center, you are bound to see motor vehicle accidents coming in. One of the things we look for on our secondary survey is a seat belt sign which can indicate a higher risk of intra-abdominal injury. These patients are often observed or admitted due to the potential for missed injuries on initial work-up. In these times of worsening hospital crowding, anything that can allow us to safely discharge patients from ED is helpful.

“When in doubt, scan it.” -some wise ED attending
This was a retrospective case series conducted at a Level I trauma center in which they identified 425 ED patients with confirmed ASBS through chart review. 415 of 425 (97.7%) of these patients received a CT scan, and they found that the overall incidence of intra-abdominal injury was 38.1% in this cohort, with 13.6% undergoing exploratory laparotomy. Initial CT scan had a 100% sensitivity (95%CI 92.5-100) for detecting intra-abdominal injury. No patients in this sample that had an initial negative CT went on to have a positive finding on repeat CT. While the sensitivity looks great, just be cautious; the lower end of the confidence interval is 92.5%, and this was a retrospective case series which could have missed patients who had more subtle exam findings that excluded them from this study. Finally, if the patient’s abdomen remains extremely tender, even with a negative CT, don’t send them home.

Patients with Abrasion or Ecchymosis Seat Belt Sign Have High Risk for Abdominal Injury, but Initial Computed Tomography is 100% Sensitive. J Emerg Med. 2020 Aug 18:S0736-4679(20)30660-0. doi: 10.1016/j.jemermed.2020.06.057. Online ahead of print.

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#3: Hypertonic Saline or Mannitol for Pediatric Increased ICP?

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In children with CNS infections leading to increased intracranial pressure (ICP), treatment with hypertonic saline (3%) had better outcomes than 20% mannitol.

Why does this matter?
Three fourths of comatose children with acute CNS infections have increased ICP. Targeting and maintaining ICP < 20mm Hg is associated with increased survival in this population. There are several agents we can use to treat elevated ICP, and we need to know which one gives these patients the best chance of survival.

Pass me the salt
This open label RCT assigned children with acute CNS infections aged 1-12 with a GCS of ≤ 8 to either treatment with 3% hypertonic saline (n = 29) or 20% mannitol (n = 28). Primary outcome, an average ICP <20 over 72 hours (measured via intraparenchymal catheter), was seen in 79.3% of children treated with 3% compared to 53.6% in the mannitol group, adjusted HR 2.6 (95%CI 1.23-5.61). Additionally, 3% showed an increase in cerebral perfusion pressure (CPP) (15.4 vs 6 mm Hg, p = 0.007), higher modified GCS at 72 hours (median 10 vs 7, p = 0.003), lower mortality (20.7% vs 35.7%, p = 0.21), shorter duration of mechanical ventilation (5 vs 15 days, p = 0.002), shorter PICU stay (11 vs 19 days, p = 0.016), and less neurodisability at discharge (31% vs 61%, p = 0.049).

While data is less clear in traumatic cases of elevated ICP, this study’s results are compelling and are consistent with a prior RCT. The next time I see a child with increased ICP, I likely will be reaching for 3% as my first pharmacologic intervention. See the comment from Dr. Michael Wolf below on what he thinks of this study.

Randomized Clinical Trial of 20% Mannitol Versus 3% Hypertonic Saline in Children With Raised Intracranial Pressure Due to Acute CNS Infections. Pediatr Crit Care Med. 2020 Sep 29. doi: 10.1097/PCC.0000000000002557. Online ahead of print.

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Another Spoonful
This is expert commentary to help you go deeper on this topic.

”Much of what we know about treating elevated ICP comes from the TBI literature. The mechanisms are interesting and important: it is likely all about brain perfusion. It is worth noting that both mannitol and 3% saline work by decreasing blood viscosity, which leads to an autoregulation-induced vasoconstriction allowing for relatively constant cerebral blood flow despite reduced cerebral blood volume – hence a fast decline in ICP if intracranial compliance is poor. The osmotic effects are slower (starting ~15-30 minutes). Blood-brain barrier (BBB) status is a huge factor. If the BBB is not intact, as is often the case in CNS infections, mannitol can accumulate in brain tissue and actually draw fluid IN rather than OUT, possibly INCREASING ICP. It’s also worth talking about CPP. While both mannitol and 3% saline raise CPP (a good thing), 3% saline did better. This difference may be related to osmotic diuresis and lower blood pressure after mannitol.

This study was interesting and impactful. Though the primary outcome was physiology-centric rather than patient-centric, it is nice to see that a patient-centered outcome (functional status measured with Pediatric Cerebral Performance Category Scale) was different between groups – favoring 3% saline.

In short, 3% saline is already the preferred agent in TBI-related increased ICP, and this study suggests it’s better in meningitis/encephalitis also.”

Dr. Michael Wolf
Director of Neurocritical Care
Monroe Carell Jr. Children’s Hospital at Vanderbilt University

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