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: intubateCOVID – How to Get First-Pass Success in COVID Patients

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When intubating COVID-19 confirmed or suspected patients, greater experience, use of RSI, use of a PAPR, and intubation in a high vs low-income country were all associated with higher first pass success.

Why does this matter?
As we all know, we are often called on to intubate COVID positive or COVID suspected patients. First pass success (FPS) is always important, but it’s more crucial in COVID patients, so we can have the viral filter in line to reduce COVID aerosols. What can we do to optimize FPS in these patients?

Let’s do this aerosol generating procedure right

Design: This was a multicenter, multinational prospective cohort from May 2020 to October 2020 from high and low-income countries to determine what factors were associated with FPS in patients with known or suspected COVID-19 who needed an emergency airway.

Results: They included 4,476 emergency tracheal intubations. These were performed by 1,722 clinicians, 607 institutions, 32 countries; 65% of cases were from the US and UK. Most intubations were performed by anesthesia, followed distantly by critical care. FPS occurred in 89.7% of cases and was associated with RSI (vs not RSI), powered air-purifying respirator (PAPR) use, prior experience intubating COVID-19 patients, and the procedure being done in a high-income country. On that last point, patients were almost half as likely to have FPS in a low vs high-income country, aOR0.57 (95%CI 0.41-0.79).

Implications: Get the best person in the room, use RSI, put on a PAPR, and hope you practice in a place with resources.

Limitations: It is not known what contributed to lower FPS in lower income countries. It may have been due to much lower videolaryngoscope use, although there was no statistical difference in this cohort between VL and DL. It also may have been that patients had more delayed and severe presentations in lower income countries.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study. Anesthesiology. 2021 Aug 1;135(2):292-303. doi: 10.1097/ALN.0000000000003791.

#2: ETCO2 and OHCA with PEA

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A rising ETCO2 in the setting of out-of-hospital cardiac arrest (OHCA) due to PEA has a higher chance of achieving return of spontaneous circulation (ROSC). If the change in ETCO2 is >20 mmHg during resuscitation, CPR efforts should be continued.

Why does this matter?
Non-traumatic PEA arrest in the out of hospital setting typically has poor survival rates. Our EMS colleagues have two available tools to measure cardiac activity and resuscitation efforts – EKG and ETCO2. How helpful is ETCO2 in guiding a PEA resuscitation?

Compressions Count!
This study evaluated the association between change in ETCO2 and ROSC in patients with non-traumatic PEA OHCA. Delta ETCO2 was defined as initial ETCO2 1 minute after placement of advanced airway, and final ETCO2 was recorded 1 minute prior to ROSC or at termination of resuscitation. A total of 208 patients were included, 32% of which obtained ROSC. A positive linear relationship was found between change in ETCO2 and ROSC. Specifically, odds ratio per 10 mmHg increase in ETCO2 was 1.74 (95% CI, p <0.001). Additionally, delta ETCO2 > 20 mmHg had 95% specificity for future ROSC.

This is consistent with prior studies. Paiva et al showed an ETCO2 > 20 mmHg at time of intubation or 20 minutes after ACLS initiation was the best predictor of ROSC, while ETCO2 <10 mmHg 20 minutes after ACLS initiation had 100% sensitivity and specificity for non-survival. Similarly, this study by Lui et al showed that a rapid increase in ETCO2 > 10 mmHg was specific for ROSC.

The study is limited by use of ROSC as the primary outcome. A more important question is how the change in ETCO2 during resuscitation impacts overall survival with a good neurological outcome.

The Association Between End-Tidal CO2 and Return of Spontaneous Circulation After Out-of-Hospital Cardiac Arrest with Pulseless Electrical Activity. Resuscitation. 2021 Aug 17;S0300-9572(21)00313-0. doi: 10.1016/j.resuscitation.2021.08.014. Online ahead of print.

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There was no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture healing BUT using NSAIDs >3 weeks was associated with higher rates of non-union or delayed union.

Why does this matter?
There has been a strong push to move away from prescribing opiate analgesics if another acceptable alternative exits. NSAIDs/COX-2 inhibitors could be used to help shift away from post-surgical reliance on opiates. To date, data have been mixed, with studies pointing in both directions regarding healing in fracture: 1) Do NSAID, COX-2, or Opioid Rxs Increase Non-Union Risk? 2) Point: NSAIDs for Fractures – More Good than Harm? 3) Counterpoint: NSAIDs for Fractures – More Harm Than Good?.

Give me a break here…

  • Design: This was a retrospective registry-based case series study of 8,693 adult patients with upper or lower extremity fractures who were treated with any surgical intervention at the fracture site between 01/1998 and 12/2018. Pathologic fractures and those with initial diagnosis of non-union were excluded. Data regarding patient demographics were utilized for propensity matching. The authors divided the dataset into 2 groups, NSAID/COX-2 inhibitor users and nonusers, and the primary outcome was set as a diagnosis of “non-union” or “delayed union” at 6 to 48 months. Secondary outcome was defined as reoperation for nonunion/ delayed union.

  • Results: 208 patients had non or delayed union (178 the former, 30 the latter). Of those, 64 patients (30.8%) had reoperation. NSAID users had a significantly lower hazard of non-union compared with matched nonusers (HR 0.69 [0.48 to 0.98], 95% confidence interval), but there was no significant difference in any other matched comparison. Kaplan-Meier analysis revealed significantly higher non-union/delayed union when NSAID durations were > 3 weeks, p=.001. COX-2 inhibitors showed no significant difference among the groups with respect to medication duration.

  • Implications: This seems a bit suspect; NSAIDs for 21 days lowers risk of non-union but 22 days increases it? And what about COX-2 inhibitors? They are left hovering in the background, neither good nor bad compared to non-users. To me, this suggests that patients who felt more pain (and thus may have used medications longer than 3 weeks) may have been more susceptible to non-union or delayed union. It does indicate that perhaps duration of medication prescribing could be a red flag to providers that care for these patients rather than type of medication. Regardless, I plan on not prescribing these patients pain medications for long periods of time and would rather seek to obtain follow up with their surgeons.

  • Limitations: The authors had no way of knowing if patients took the NSAID/COX-2 inhibitor medications they were prescribed, which specific medications they took, or whether they took over-the-counter NSAIDs. Additionally, the common data model (CDM) used for this work was still in early stages, and the multicenter database was not set. Lastly, the work was limited in that many factors known to be associated with non-union (smoking, patient occupation, etc.) were not examined.

Overall, while this work supports the safety of NSAIDs and COX-2 Inhibitors for fracture healing, caution is still necessary when prescribing.

Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?: A Propensity-Score-Matched Study. J Bone Joint Surg Am. 2021 Aug 4;103(15):1402-1410. doi: 10.2106/JBJS.20.01663.

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