Dal PoCUS Fellowship – Journal Club – Feb 2021
Dr. Mandy Peach CCFP-EM
PoCUS Fellow
Dalhousie University Department of Emergency Medicine
Dr. Mandy Peach CCFP-EM
PoCUS Fellow
Dalhousie University Department of Emergency Medicine
Dr. Melanie Leclerc CCFP-EM
MSK PoCUS Fellow
Dalhousie University Department of Emergency Medicine
Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review
Allyson Cornelis, R1 iFMEM
Hosted by Dr Andrew Lohoar
Charles V. Pollack, Jr., M.D., Paul A. Reilly, Ph.D., Joanne van Ryn, Ph.D., John W. Eikelboom, M.B., B.S., Stephan Glund, Ph.D., Richard A. Bernstein, M.D., Ph.D., Robert Dubiel, Pharm.D., Menno V. Huisman, M.D., Ph.D., Elaine M. Hylek, M.D., Chak-Wah Kam, M.D., Pieter W. Kamphuisen, M.D., Ph.D., Jörg Kreuzer, M.D., Jerrold H. Levy, M.D., Gordon Royle, M.D., Frank W. Sellke, M.D., Joachim Stangier, Ph.D., Thorsten Steiner, M.D., Peter Verhamme, M.D., Bushi Wang, Ph.D., Laura Young, M.D., and Jeffrey I. Weitz, M.D.
BACKGROUND
Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.
METHODS
We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures.
RESULTS
A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals.
CONCLUSIONS
In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.)
http://www.nejm.org/doi/full/10.1056/NEJMoa1707278
Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80. doi: 10.1164/rccm.201507-1294OC.
Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill.
Semler MW1, Janz DR2, Lentz RJ1, Matthews DT1, Norman BC1, Assad TR1, Keriwala RD1, Ferrell BA1, Noto MJ1, McKown AC1, Kocurek EG1, Warren MA1,Huerta LE1, Rice TW1; FELLOW Investigators and the Pragmatic Critical Care Research Group.
Patients: Adult patients in an American Medical ICU requiring Rapid Sequence Induction of Anesthesia
Intervention: Usual Care (that includes bagging, biped) with the addition of Hi Flo Nasal Cannula during the preoxygenation and intubation.
Comparison: Usual Care (that includes bagging, BiPap).
Outcome: Lowest Oxygen Saturation.
A Randomized open table intention to treat pragmatic trial in 146 patients.
The session was great fun and was greatly enriched by the telepresence of Dr George Kovacs of AIME fame. Many thanks to Dr Mark Tutc
Please find below a summary of the appraisal and subsequent discussions. The appraisal structure is from cebm.net
Bottom Line. High flow Nasal cannula is still likely to be of benefit in preventing desaturation during Rapid Sequence Induction of Anesthesia.
Further Commentary By Dr George Kovacs – Here is an excerpt from our Oxygen delivery chapter:
There has been some controversy regarding the value of HFNO for apneic oxygenation with data from critical care patients demonstrating mixed results in the use of HFNO during the apneic period of an RSI. (Miguel-Montanes et al, 2014)(Vourc’h et al, 2015)(Patel & Nouraei, 2015)(Semler et al, 2016)(De Jong & Jaber, 2016) The findings that HFNO provided no added benefit in two of these studies seemed inconsistent with physiologic principles of preoxygenation and apneic oxygenation. Methodologically, there were inconsistencies in airway maintenance maneuvers between groups with the control group receiving PPV with an open airway as opposed to HFNO who had no airway opening documented. Vourc’h et al, 2015) Patients were reasonably well preoxygenated and commonly had PPV (NIV or BVM support) until laryngoscopy with relatively rapid intubation times (particularly in HFNO group) which would make the benefit of HFNO less apparent. (Semler et al, 2016) Collectively these studies do help us appreciate pearls and pitfalls of preoxygenation and apneic oxygenation using HFNO:
Further Commentary by Dr James French
Thats great, looking forward to getting the book!
With regards point 1 above 1. “For normal patients with normal lungs, preoxygenation is relatively easily achieved but is likely best performed with passive closed system BVM at 15 l/min for at least four minutes. For patients with increased minute ventilation needs, the addition of standard HFNO under a BVM with PEEP allows additional flow for preoxygenation and provides CPAP conditions.”
I understand the excerpt is a physiological discussion so this may be covered in later chapters….
Even in the patient with no appreciated increased risks for hypoxia or assessed as having normal lungs, it may be logical to preoxygenate with a BVM, hi-flo nasal cannulas and a peep valve as routine for a number of system and human factors reasons, namely:
Should all BVMs have a peep valve to ensure it is a closed circuit?!