Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact
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About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


References:

  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. 2014 Jun 24;:1–9. [free pdf]
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.

CEM FOAMed network

CFN Logo

The College of Emergency Medicine is the body responsible for training all the wonderful UK emergency medicine trainees and represents the speciality in the UK. The trainees in Ireland do the UK exams so the specialties in both countries have a fairly close relationship.

The college’s main online educational presence in recent years has been the ENLIGHTENme platform. There’s been some good stuff on there but it’s behind a log in and not immediately accessible in the way FOAMed resources have been.

With the rise of FOAMed and it’s influence on education of emergency physicians, it’s only natural that the college would want to embrace the idea.

Simon Laing (of the HEFT EM Podcast) is the college lead for this and he has been involved in recruiting people from the different regions of the UK and Ireland to provide FOAMed resources. Ultimately the goal is to ‘map’ the college curriculum. Somewhat similar to my own little anatomy project but on a much broader scale.

The UK exams for emergency medicine are a different beast to the Aus/NZ ones so it’s a natural that there’ll be a need for some more specifically directed resources.

The CEM FOAMed Network (rejoicing in the acronym CFN) is a project in development. The website is in the pipeline and the introductory podcast is now live on iTunes.

Please check it out and look out for more FOAMed resources in the near future.

Conflicts

  • I am the regional lead for Ireland for the project
  • The college was kind enough to provide me some small amount of funds for a microphone.

Tasty Morsels of EM 041 – Acute Urinary Retention

[Featured Image: Frivadossi, Wikimedia Commons]

As always, this is from the ever expanding google doc on bits and bobs I read and learn from.

This time:

ED Management of acute urinary retention. EB Medicine

  • Causes
    • Men – think prostate
    • Women – bladder masses, gynae surgery and prolapse
    • Drugs: calcium channel blockers (i didn’t know this), anticholergics (i did know this one)
    • Spinal cord compression is probably the real emergent cause we need to think of
    • In a similar manner to other neuropathies, diabetics can get a diabetic cystopathy resulting in AUR.
  • The big take home should be this: you need to bloody well examine them. There is a real (and justifiable) desire to just slip in the catheter (or worse get someone else to do it) and get disposal nice and quickly. But as simple as most AUR is, you will miss important things (say spinal cord compression, or a penile tumour, especially in the patient with dementia or non-verbal patients) if you don’t physically get involved with the gorey details.
  • there’s some ‘himming’ and ‘haaing’ over whether to put a finger in the rectum. The main concern seems to be in prostatitis and seeding the blood with a prostate exam. They’re right to say that there’s no evidence of this causing harm. But that works both ways – there’s no evidence either way. There’s not a great deal of diagnostic value here I don’t think. The bigger issue is whether to put a catheter through an infected prostate. I figure if they’re in retention then I do it, and they get a nice chaser of gentamicin and an admission.
  • there’s some interesting stuff on urine samples for prostatitis. You can collect wee at lots of different points of the wee cycle and then massage the prostate a bit and get another few mls. There’s even a study looking at semen cultures for prostatitis. I imagine if I had prostatitis the last thing I might be able to do is provide a semen sample…
  • getting the patient to exhale when the tip is at the prostate seems to be of some use in relaxing the relevant sphincters
  • an episode of hypotension following bladder decompression is common due to a reflex response in reduced vascular resistance. Doesn’t mean the you don’t have to think about whether that patient’s severe abdo pain was actually a AAA rather than AUR…
  • they (sensibly) state that if it’s a simple catheter and no reason to think infection then antibiotics are not indicated. Very different from the raging, septic prostatitis
  • they quote the common figure of 2 in 3 patients requiring repeat catheterisation if the catheter is immediately pulled. They also note that those with a spontaneous AUR (which is likely prostatic hypertrophy in origin) is more likely to need a second catheter than those with a precipitated cause (eg infection or constipation).
  • they suggest that the 2 in 3 rate of recurrence mandates that the catheter is left in whereas I think that “hey, I have a 1 in 3 chance of not needing this – i’ll take those odds and come back if I can’t pee again”
  • catheters that get stuck and can’t be removed are usually due a ridge forming on the balloon during deflation and can be dealt with very slow reinflation and deinflation. The inflation channel can also be cut. Interestingly they say that filling the balloon with 10mls of mineral oil will dissolve the balloon in about 15 mins and allow removal. I have no idea if this applies to all makes.

IAEM 2014

The Irish Association for Emergency Medicine are hosting their annual scientific meeting this year in Dun Laoghaire. They’ve just launched the website for the event where you can find all the info you need. This year’s event is being hosted by one of former hospitals, St Vincent’s University Hosptial Dublin where both this site’s own David Menzies and our training program director, John Ryan are based.

It’s exciting to hear that FOAM’s own Scott Weingart is coming as our keynote speaker. Upstairs care, downstairs and all the way across the pond it seems!

It’s sure to be a great event and of course it’s open to those both north and south of the border and it would be a delight to see even a few of you over from the UK too.

As with most scientific conferences, there is the opportunity to submit posters and oral presentations and all the details are on the site.

See you there.

IAEM 2014 site

[Conflict of interest: I helped put together the website for the event for which I may or may not receive beer. Here's hoping...]

Tasty Morsels of EM 040 HSV in Kiddies

[Featured Image: Ben Tillman, Wikimedia Commons]

Another review from the EB Medicine series of publications. Remember this comes free with EMRA membership if you’re a trainee. Along with EM:RAP, Emergency Medical Abstracts and lots of other good stuff. This time it’s Paeds:

Pediatric Herpes Simplex Virus Infections: An Evidence-Based Approach To Treatment. Paediatric Emergency Medicine Practice. 2013 Dec 24;:1–20.

Sorry it’s a bit longer than usual but I found a lot of important stuff in here, a lot of new to me.

  • CytoMegalo Virus, Varicella and Epstein Barr are all types of herpes virus
  • HSV can be transmitted even without visible lesions
  • HSV-11 tends to reside within the trigeminal ganglion, while HSV2 commonly resides in the sacral ganglia which makes sense with the clinical distribution of oral HSV-1 and genital HSV-2
  • Lifelong latency and periodic recurrences are hallmarks of HSV infections. As Mark Crislip might say, Herpes is for life not just for Christmas…
  • in herpes encephalitis 1/3 is primary, 2/3 are reactivation. Just because they don’t have a cold sore doesn’t mean it’s not HSV encephalitis
  • HSV-1 prevalence is 90% by old age
  • HSV encephalitis has 2 peaks: <20 and >50. Virtually all are HSV-1
  • most neonatal HSV (non-encephalitis) is HSV-2
  • peripartum HSV in 3 categories:
    1. disseminated (think signs of sepsis, respiratory collapse, liver failure, disseminated intravascular coagulopathy, and pneumonitis.)
    2. CNS disease (with or without lesions. think seizures, irritability, a bulging fontanel, and temperatures either high or low. Most of these will have skin lesions at some point)
    3. disease limited to skin eyes and mouth
  • mortality for untreated disseminated disease is 85% and even if treated it remains high
  • common differentials for the rash include
    • erythema toxicum or pustular melanosis
    • It is important to note that both of these present in the first few days after birth, unlike disseminated HSV which typically presents after at least 10 days or so. I remember seeing pustular melanosis as a paeds doc doing baby checks and being almost as freaked out as the parents were. Reassurance from the boss was all both of us needed.
  • in CNS HSV 5-10% of LPs can be normal initially. How on earth do you even make the diagnosis in these kids then?
  • they note that LFTs might be useful as they are typically quite abnormal in babies with disseminated disease. I’m not sure this is fit as a rule out but in the crashing infant with crappy LFTs it might prompt you to consider it in addition to the usual bacterial sepsis.
  • if you’re looking for CNS disease with imaging then the temporal lobes are where the money is and MRI is the test to see it. However you will sometimes see it on CT, and i’ve seen it missed on CT by those who sit in dark rooms for a living.
  • the first drug for this was something called vidarabine. When aciclovir came out they did a randomised trial between the two and found no difference. And aciclovir rules the day due to its apparent favourable side effect profile (ring a bell for amiodarone v lidocaine or verapmail v adenosine anyone?)
  • Kaposi-Juliusberg Varicelliform Eruption – you’ve all heard of that right? It’s important and potentially life threatening so get on it!
  • Some others
    • herpes gladiotorum – typically athletes getting HSV-1 through abraded skin
    • herpetic whitlow – the one on the finger that looks like a paronychia but isn’t