Grand Rounds Recap 9.28.22

Morbidity and Mortality WITH Dr. Mullen - DKA QI/KT WITH Dr. Shaw and Dr. Glenn - High Pressure Injuries WITH Dr. Irankunda -Research WITH Dr. Freiermuth

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Morbidity and Mortality WITH Dr. Mullen

Sepsis

• Issues leading to difficulty identifying sepsis

  • Triage Vitals

    • Poor integrated reliability

    • Missing data

    • Varying methods of obtaining vitals lead to discrepancies

  • SIRS Criteria: not all patients with sepsis present with SIRS criteria (elderly, immunocompromised, medications affecting HR, etc)

    • Temp >38 or <36

    • HR > 90

    • RR > 20 or PaCO2 <32

    • WBC >12 or or < 4, or >10% bands

• Treating sepsis

  •  Use the order set

  • Use dotphrase .sepreassess to document reassessment and time stamp

Spontaneous Bacterial Peritonitis and Long QT

• SBP: ascitic fluid infection without an evident intra-abdominal surgically treatable cause

  • In hospital mortality 18-30%

  • Delay in recognition of SBP, paracentesis, and antibiotic administration are linked to increased mortality

  • Presentation: can vary with fever, abdominal pain, AMS, diarrhea, ileus, hypotension, hypothermia but up to 13% of cases are asymptomatic

  • Diagnosis: paracentesis with positive ascitic fluid culture or PMN >250 cells

  • Who needs a paracentesis?

    • Any patient with clinical suspicion of SBP

    • Any patient with cirrhosis and ascites admitted to the hospital 

  • Management: 3rd generation cephalosporin

• Long QT 

  • Prolonged QT

    • Men >440ms

    • Women >460 ms

    • >500ms associated with increased risk of torsades de pointes

  • Several etiologies of prolonged QT

    • Electrolyte derangements, including potassium, magnesium, calcium

      • Important to monitor and replete electrolytes

    • Medications: antiarrhythmics, antidepressants, antibiotics, diuretics, antiemetics 

    •  Hypothermia

    • Intracranial and cardiac etiologies

Acute Anemia in Sickle Cell patients - Hydroxyurea Toxicity

• Etiologies of acute anemia in sickle cell patients

  • Splenic sequestration syndrome

    • Typically occurs in children ages 6 months-5 years but can occur as early as 2 months; age of presentation also depends on HbSS vs HbSC

    • Occurs as a result of sickled RBC becoming congested in splenic sinusoids → splenomegaly and anemia

    • Presentation: abdominal pain, hypotension, tachycardia, evidence of volume depletion 

    • Labs: low hemoglobin, elevated reticulocyte count

  • Aplastic Crisis: transient failure of erythropoiesis leading to anemia

    • Etiologies: often viral including parvovirus B19, CMV, EBV

    • Presentation: hypotension, tachycardia, pallor

    • Labs: low hemoglobin, low reticulocyte count

  • Hydroxyurea Toxicity

    • MOA: affects DNA replication leading to arrest of DNA synthesis in S phase of cell cycle

    • Used in sickle cell anemia because HU shifts gene expression favoring production of fetal hemoglobin

      • Fetal hemoglobin is not affected by sickle cell mutation and leads to less sickling → less vaso occlusive crisis

    • Toxicity:

      • Narrow therapeutic index

      • Can lead to myelosuppression given HU’s mechanism of action 

      • Consider HU toxicity as possibility of acute anemia and/or pancytopenia in sickle cell patients

ED Extubation

• Unfortunately not a lot of data or studies on extubation in the ED and safety of extubation

• When considering extubation, evaluate for:

  • Ability to oxygenate

  • Ability to ventilate

  • Airway protection

  • Anticipated clinical course

  • Resolution of critical illness state

• Evaluate objective data (labs) prior to considering extubation to ensure safety 

PE and DOACs

• Rivaroxaban: Factor Xa inhibitor

  • Half life: 5-9h but up to 11-13h in elderly

• Lab monitoring

  • Need specific lab calibrated for DOACs for most accurate data, which is not available at UC

  • Can use Anti-Xa heparin lab to rule out clinically relevant drug concentrations (not useful for quantification)

  • Absorption:

    • Higher doses of rivaroxaban (15-20mg) have increased bioavailability when taken with a meal 

    • There are numerous drug interactions that can affect absorption of DOACs

• Cancer patients are at increased risk of breakthrough PE/DVT even when taking anticoagulation

Cardiac Arrest

• Patient presented to the ED with inferior STEMI and subsequently had witnessed cardiac arrest in the ED. ROSC was achieved and the patient was taken to the cath lab where he was found to have 100% RCA occlusion with TIMI 3 flow s/p DES. Patient was discharged within 48 hours of presentation neuro intact. 

• What we do is important!

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DKA QI/KT WITH Dr. Shaw and Dr. Glenn

• Epidemiology

  • 37 Million people in the US or about ~11% of the population

  • 2x the healthcare cost of other Americans

  • 1 in 7 healthcare dollars are spent treating diabetes and its complications

  • Increasing rates of ED visits for Hyperglycemic emergencies 

• Pathophysiology

  • Definition

    • BG > 250, pH </= 7.3, Bicarbonate </= 18, Anion gap > 17

    • Resolution means a BG < 200 as well as (2 of 3) pH >/= 7.3,Bicarbonate >/= 18 and Anion Gap <= 12

  • How it occurs

    • Insulin deficiency leads to decreased glucose utilization, increased lipolysis, increase protein breakdown and increased glycogenolysis 

    • Results > Hyperglycemia and Ketosis 

  • Terminology

    • DKA - Absolute insulin deficiency

      •  ketoacidosis treated with Insulin and IVF

      • Treatment Complicated by HypoK,HypoMg, and Hypoglycemia 

      • Anion gap elevated

      • Common

    • HHS - relative Insulin deficiency

      • Elevated serum osmolality

      • Treat with IVF

      • Treatment complicated by HypoK,Hypophosphatemia, Hypogly,Cerebral edema

      • Rare

      • Serum osmols > 320

• Treatment

  • Fluids

    • Protocol 

      • Give 20cc/kg of balanced crystalloid, reassess 

        • If stable then continue 2x maintenance if unstable consider repeat boluses

    • Normal Saline 

      • Has been shown to cause hyperchloremia leading to a decreased renal blood flow

      • Increases extracellular fluid expansion

    • Balanced Crystalloids (LR, Normosol, Plasmalyte)

      • Improved renal blood blow when compared to NS

      • Improved in Travis half expansion compared to NS

      • Decreased incidence of death, RRT and persistent renal dysfunction

      • Improved UOP and BP in DKA

      • Improved Bicarbonate levels Post resuscitation in DKA

  • Potassium

    • If less than 3.3 give 20-30mEq/hr until K is greater than 3.3

    • If > 5.2 do not give K but recheck every 2 hours

    • If 3.3 - 5.2 add 20-30mEq of K+ in each liter of IVF

  • Insulin

    • SubQ insulin is likely as effective as IV insulin for mild DKA

    • If mild DKA use SubQ insulin Lispro 0.3U/kg and can refuse with 0.2U/kg every 2 hours. Once BG is less than 250 change to lispro 0.1 U/hg every 2 hours until resolution 

    • If not mild DKA use IV insulin 

  • Use of Bicarbonate 

    • If pH is less than 6.9 then put 2 amps of Biarb (100meq) in 400ml of sterile water with KCl and run at 200ml an hour for 1 HR repeat until pH > 7

    • This can be repeated every 2 hours until pH is greater than 7

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HIgh Pressure Injuries WITH Dr. Irankunda

Patient comes in with a pressure washing injury to his left index finger. Patient is right handed. Injection was only with water and no other additives 

• Need around 100PSI to break the skin and most high pressure injuries happen with forces > 1000PSI

  • Concern is not only the injection force but also what is in the injection 

  • Water alone is the best case scenario 

  • Most injections involve some kind of solvent or cleaner

    • Risk of amputation 

      • Diesel 72% > 55% paint thinner > 44% oil > 18% grease > ~0% water and Air 

  • Most injection injuries 

    • Male

    • Non-dominant hand 

    • Index finger

    • Unconcerning physical exam 

• Management 

  • Irrigation

  • Antibiotics

  • Limb evaluation

    • If any deficits then they need more urgent evaluation

    • If any solvents that is urgent/emergency hand eval 

    • If only water or air and 100% normal exam can consider outpatient in conjunction with hand

  • Consider Steroids for organic solvents 

  • TDaP as needed

• Crucial Pieces of information

  • Composition of injected material

  • Time from injury to treatment

  • Force of injection 

  • Volume of injection

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Research WITH Dr. Freiermuth

• The 2x2 box

  • Sensitivity   True Positives / ( True positive+False Negative) 

    • Percentage of patients with the disease that recieve a positive test 

  • Specificity True Negative / (True Negative + False Positive)

    • Percentage of patients without the disease that recive a negative result 

  • Positive Predictive Value  TP/(TP+FP)

  • Negative Predictive Value  TN/(TN+FN)

• Hypothesis testing

  • Type 1 error- statistical significance appears when there is no significance (false positive)

  • Type 2 error- statistical significance does not appear when there is significance (false negative)

  • Power- try to overcome error, number needed to enroll in order to detect a predetermined difference between groups, should be calculated BEFORE a study starts

  • Mean- average value, use when data normally distributed

  • Median- middle value, use with data skewed, lots of outliers

  • P values- indicates statistical significance (NOT clinical), illustrates the probability of a difference

  • Confidence intervals- range of values that includes the true parameter (95% indicates that in 95/100 runs, the value falls within that range), narrow equals more confidence

• Study Design

  • Cohort study- everyone with a disease included, identify a particular exposure, then look at difference in outcomes

  • Case-control study- start with disease outcome and then look back to identify exposures, have control group without disease and also look at rate of exposures in that group

  • Systematic review- summarizes evidence across studies

  • Meta-analysis- synthesizes results across studies using stats