Fecal Microbiota Transplant related Bacteremia

Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant




Link to Abstract

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Pulmonary Embolism Guidelines 2019

These are the 2019 European Society of Cardiology and European Respiratory Society Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism. I must say, these are my favorite guidelines for PE and they came out just a few weeks ago on August 31st. It seems as if PE is just on every differential, as it respectfully should be, on anyone who is hypotensive with chest pain and short of breath. You definitely have to think about it, but that doesn't mean that everyone needs a CTA of the chest to rule it out. Many times a good history and physical can rule it out.

The images in this article is where much of the value is. The flowcharts simplify the thought process. I encourage those of you who have the ability to learn how to do some simple echocardiography to learn the skills of at least finding the windows. You'll be able to gain a TON of information just by laying the probe on the chest. This is one of those PDFs that you should definitely have accessible and refer to it often until you basically have these guidelines memorized.

A big hat tip to the authors. Again, I LOVE this paper.

-EJ

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

Link to Abstract

Link to FULL FREE PDF this may or may not work

Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019; published online Aug 31.

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NPO after Midnight: What do the guidelines say?

Is your shop still using strict NPO after midnight for its surgical patients? It’s time to talk to the powers that be to have this changed, supported by evidence, of course.

The controversy of “Strict NPO After Midnight” has been ongoing for many years now as the data has suggested it’s silly but still performed. Well, the American Society of Anesthesiologists put together a task force in 2017 to put an end to the silliness. Let’s try to make the horrible experience of being hospitalized a little less horrible for our patients. #endthenpo

A 🎩 tip to the authors. Happy Sunday!








Link to article where you can download the PDF

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. Anesthesiology

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Corticosteroids and GI bleeds: Do We Really Need To Worry?

Link to Abstract

Butler E, Møller MH, Cook O, et al. The effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in critically ill adults: a systematic review with meta-analysis. Intensive Care Med. 2019;45(11):1540–1549. doi:10.1007/s00134-019-05754-3

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Fecal Microbiota Transplantation: So Much to Learn

Link to Abstract

Link to Full FREE Article

Dai, M., Liu, Y., Chen, W. et al. Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit Care 23, 324 (2019). https://doi.org/10.1186/s13054-019-2604-5

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Thiamine and Renal Failure in Septic Shock Patients

Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today. It's challenging to stay up to date in everything. I digress.

Some would quickly bash this study for it being small (n=70) and a post-hoc secondary analysis of a pilot study. I am not going to do that. Why not? Well first of all, I do not participate in research myself. Just reading and enjoying these studies. Also, thiamine has no side effects described in the literature. Third, it is an inexpensive medication. Fourth, if it does turn out to decrease the incidence of acute kidney injury and the need for renal replacement therapy, aren't you going to feel guilty for not adopting these strategies for your patients? I hate resorting to that but my responsibility is for patients. What happens if this data is wrong? Nothing. What happens if this data is right and no one does anything for several years? Many patients may suffer.

This article is completely free and I encourage you to download it and read it for yourself. Amongst the points illustrated by the authors, they mention that it's not only perfusion that injures the kidneys during sepsis. There are other factors listed in the article. The way that it is postulated that thiamine works for these patients is by assisting in the mitochondrial dysfunction. Data that I have found not listed in this article shows that thiamine deficiency could have an incidence between 20-70% of critically ill patients. 

What they found was 21% of the patients in the placebo arm of the trial went on to need dialysis. Just one patient, or 3% in the thiamine group went on to require this. The authors note that acidosis was the primary indication for dialysis in 66% of the patients who required it. I personally would like to dig deeper into these numbers as there is some data that thiamine administration helps decrease lactic acidosis. 

This data should make you wonder if the strategy that many clinicians take of providing more IV fluids to patients whose renal function deteriorates is the correct strategy. Are we going to look in the mirror in a decade and want to punch our past selves in the face?   

- EJ

Link to Abstract

Link to Full Article

ADDENDUM: The prospective RCT is going to be completed in July 2022. Here is the link to clinicaltrials.gov's study details here: LINK

Moskowitz A, Andersen LW, Cocchi MN, Karlsson M, Patel PV, Donnino MW. Thiamine as a renal protective agent in septic shock. A secondary analysis of a randomized, double-blind, placebo-controlled trial. Anns Am Thorac Soc. 2017;14(5):737–41.

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Thiamine, Ascorbic Acid and Corticosteroids: The Mechanisms by which they should help in Sepsis

Want some nerdy stuff? Well this is some nerdy stuff! I'm taking a nice deep look at this figure. I am not going to lie to you at this moment, October 19th, and tell you I know what all this means, because I don't. But people who are more intelligent that I am have suggested that these are the mechanisms by which thiamine, ascorbic acid, and corticosteroids should help in the treatment of septic patients. I have a lot to learn.

I hope I don't get dinged for copyright stuff but honestly if this offends you, let me know. I will take it down. I will likely go deeper into this article at a later time. Wanted to share this image with you right now, though.





Link to Abstract

Link to FREE FULL Article

Moskowitz, A.; Andersen, L.W.; Huang, D.T.; Berg, K.M.; Grossestreuer, A.V.; Marik, P.E.; Sherwin, R.L.; Hou, P.C.; Becker, L.B.; Cocchi, M.N.; et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: A review of the biologic rationale and the present state of clinical evaluation. Crit. Care 2018, 22, 283.

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Delirium in Mechanically Ventilated Patients: Let the Natural Light in!

I have great disdain for delirium. Natural light brings me great joy. Today, for example, the sun isn't shining bright. The day is cloudy and gloomy. I am, in turn, a little grouchy. Daylight savings is coming and I'm already upset about it. I can turn on the light but it won't be the same. This study was published today. How's that for so fresh and so clean?

Preventing and treating delirium is something we haven't quite figured out just yet. But studies like this one help us chip away at that giant piece of rock to eventually present a great sculpture. Bad analogy? Yep! In this study, the authors were curious to see whether patients having natural light would affect the incidence of delirium in patients who are on the ventilator (primary outcome). The secondary outcomes included the "duration of delirium, duration of coma, use of antipsychotics to treat agitation, the incidence of hallucinations, the incidence of self-extubation, duration of mechanical ventilation, ICU and hospital length of stay, ICU and hospital mortality."

This was a single centered trial with 195 patients. Out of their measured outcomes, they noted that the patients exposed to natural light had a reduced incidence of severe agitation (p=0.04). In addition, the patients exposed to natural light also had fewer hallucinations (p=0.04). Fortunately, this study is free and you can download it and read it yourself. I like natural light. It's free. It may not ameliorate delirium, but it is another tool in our tool belt to make these patients better.
-EJ

Link to Abstract

Link to full free PDF

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Fluid Resuscitation of Trauma Patients: 0.9%NaCl (saline) or Plasma-lyte?

I am not a trauma surgeon. I am not a trauma physician. I do not take care of trauma patients in my current practice. I did several rotations in the trauma intensive care unit during my fellowship training but by know means am I going to pretend to have the knowledge that my colleagues who do that every day have. The study I am going to be discussing today is a pilot study.

The authors were concerned about the metabolic acidosis that occurs from the elevated chloride concentrations in 0.9% NaCl which is 154mmol/L. Remember, reference values in the lab for chloride levels are between 98 and 109mmol/L. Also, there is data suggesting that an increase in chloride levels by just 5mmol/L could have deleterious effects on our patients. This hyperchloremic metabolic acidosis is not something new, we've known about its effects on the kidneys for decades now. I guess we've just been ignoring it.

I am a fan of whole blood to resuscitate trauma patients, but I my knowledge on the matter is weak. At the time being, patients receive a significant amount of crystalloids for resuscitation. The authors chose to use NS and plasma-lyte due to the fact that lactated ringers is contraindicated with blood products as it allows the blood to coagulate as it goes in due to the calciums effect on citrate.

Surgeons are trained, from my experience, to focus on base excess. When a patient you're taking care of them is sick, and you're giving them a call to give them the heads up of what's going on, one of the first questions you need to be prepared to answer is "what is the base deficit"? Plasma-lyte is a balanced salt solution that I have reviewed numerous times on instagram, my website, and youtube. Plenty of resources out there from me explaining this fluid. This focus on base excess is why they made this

They ended up with 46 patients enrolled in the study.

Plasma-lyte corrected the base deficit faster than 0.9% NaCl. Primary outcome achieved. Patients reached and remained in their normal acid-base physiology longer.

They also found that 0.9% NaCl leads to hyperchloremic metabolic acidosis, decreased serum bicarb levels, and worse base deficit.

Patients also had increased urine output with plasma-lyte compared to saline solution. There is some concern about whether gluconate causes some sort of increased urine production but this is not specified in this paper.

Some institutions worry about the added cost of plasma-lyte, which is approximately $1 on top of the cost of NS or LR depending on the institution and their contract. This study showed that providing plasma-lyte kept serum magnesium levels closer to normal (p=0.007). If you are a bean counter, you could potentially save some money by using plasma-lyte due to less cost of magnesium replacement. I may be stretching a bit but at least I am admitting that I'm stretching. The patients needed about 4gm of Mg in the NS group and no replacement in the PL group. I take back the part of me stretching. The authors state that the difference at their institution of cost between NS and PL is $0.76. 2gm of magnesium is $5.19. That means that PL may end up saving money and additional testing.

All in all, this is a pilot study. I have not personally seen the actual study. If you all have, feel free to correct me. This is not a full free article, unfortunately.

-EJ

Link to Abstract

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BiPAP should not be used in Immunocompromised patients

This was a post-hoc analysis of the FLORALI trial that I have reviewed before on this medium. In that study they compared patients who had hypoxemic respiratory failure by putting them on 1:1:1 on high flow nasal cannula (HFNC), standard oxygen therapy, and non-invasive ventilation (NIV aka BiPAP).

My interest was piqued in trying to find out what they defined as immunocompromised patients. They looked at patient with hematologic and solid malignancies, AIDS, drug induced, and steroid related. The etiology for the respiratory failure in these patients was mostly for pneumonia, whether opportunistic etiology or not.

To make it simple, they found that patients treated wit HFNC did better than patients who received NIV regarding rates of intubation as well as mortality.

Frat J-P, Ragot S, Girault C, et al. Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial. Lancet Respir Med 2016;4:646–52.

Link to Abstract

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HYPERION: 33 vs 37 for targeted temperature management in cardiac arrest

I am going to be all over the place with this takedown. I’m a bit upset at what may happen as a result of this publication. I really wanted it to be a good study but it’s not. You’ll see why shortly. 

The good news is that there’s no difference in adverse effects to the patient by cooling them, just a lot of added cost. That’s my tidbit for those physicians who are going to take this data and run with it as if it’s gospel. 

My practice prior to this article was to do a normothermia protocol of 36 degrees after the NEJM trial from 2013. Is this one going to change my ways... from the outset it appeared as if it will, but, spoiler alert, it won’t. 

The objective of this study was to sort out whether we should cool our patients to 33 or normothermia of 37 in patients who suffer cardiac arrest with a non-shockable rhythm. 

Within the methods, they excluded patients who were down for >10 minutes prior to chest compressions. This is hard to determine many times as families are never quite sure. I complement the 25 ICU’s who recruited 584 patients in this study. The fact that they allowed patients to be recruited for 300 minutes from their arrest time gives us insight that you don’t have to make the determination immediately on whether you have to cool the patient. Then again, such a high percentage did poorly that we don’t really know what’s the best time to get started. 

In how they rewarmed patients, it’s important to note from a practice standpoint that the sedation was tapered when the temp got above 36. That’s a nursing question I often hear. 

Within their outcomes, the primary was a favorable 90-day Cerebral Performance Scale where they wanted to see in particular if the patients had either a score of 1 or 2. A score of 1means Good cerebral performance or minor disability. A score of 2 means moderate disability. They called the patients or families on the telephone for follow up. People lie. I wish they would’ve had someone lay eyes on the patients. But people lie in both groups so this should be no big deal. should be. But it isn’t. You’ll see why. 

The secondary outcomes were all the typical ICU stuff: mortality, days on the vent, LOS in ICU and hospital, infections and adverse hematologic events. We know that cooling causes degrees of coagulopathy. 

With in the results, the authors assessed 2723 patients over the course of 4 years. That’s A LOT of cardiac arrests! Then again, 15 ICU’s. I imagine they’re all busy institutions. 

I was happy to see that an intravascular cooling catheter was only used in 14.8% of patients. I have always thought that they were a little too invasive for my tastes, especially if/when they start oozing. 

When looking at the actual outcomes, the best case scenarios still only had a 10.2% incidence of a CPC of 1 or 2. This is not a cure, team. Patients still do terribly. It’s helpful to let families know what to expect when a patient arrives in our ICUs in cardiac arrest. 

More than 80% of patients died in both groups. 81.3% vs. 83.2 in the 33 vs. 37 respectively. All of the secondary outcomes showed no difference. 

The supplementary text provides data as to how they handled withdrawal of care. Imaging was curiously nowhere to be seen anywhere in the paper. They do not mention abnormal CTs or any type of MRIs anywhere in this paper nor the supplementary text. I would be curious if they found anyone with loss of gray-white differentiation who did well. I wonder if they omitted that information so that they could collect a large enough sample size and families wouldn’t withdraw prior to completion of the study. Hmmmmm.  

I respect the heck out of the authors in the way they disclosed their limitations. They admitted that an outcome change in a single patient would make the primary outcome not significant. What am I supposed to do with that?!?! If one person lied about how well they were doing over the phone it would change the conclusions of the entire 4 years of work! This is why I don’t do research. 

The other caveat to the study is that they let the patients in the 37 degree group develop fevers. Correct me if I’m wrong but didn’t a subgroup analysis in the 33 vs 36 study from several years ago show that avoiding fever is the most important component in these patients? In my practice I discuss with the nurses that we need to be prepared for the fever and have meds on the medication list, not for if it will happen, but rather for when it will happen. Considering the study got started in 2014, this is something that hopefully they knew going into the study. 

I’m sticking with 36 in my practice. What do you all think? 

A hat tip to the authors. 

-EJ

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IV Vitamin C and ARDS: CITRIS-ALI

Here's my bias before I even read the article. I want to see a positive response in providing Vitamin C/ascorbic acid in patients who have Acute Respiratory Distress Syndrome. Why? Because I want me patients to do better with treatments that are inexpensive and easy to manufacture rather than the latest immunologic that ends in -mab and costs tens of thousands of dollars. If before you read this summary, you already think that Vitamin C is a bunch of bullpoop, you need some deep reflections in the mirror. You SHOULD want it to work. Now whether it does or doesn't is different and that's where the data comes in to play.

Ultimately, I'm sure I am going to write far more than what IG will allow me to write do you're more than likely going to have to go to my blog to read my thoughts.

The Study Drugs
Before we even get started, we need to look at the study drugs, or lack thereof. The cocktail that was used in the Marik trial that was monumental in finding a mortality benefit in sepsis included ascorbic acid at 1.5gm q6, thiamine 200mg, and steroids. There is a rationale as to why these three go together that Dr. Marik explains far better than I could ever explain. The three are necessary today. Heck, even Gianfranco Meduri has been using steroids for ARDS for years and it's not part of this study. Red flag number one. Not hating on the authors, I am just saying. Haven't finished reading on it yet. Reserve the right to change my mind. In fact, a quick search shows there's no mention of the word "thiamine" in the entire paper.

Outcomes
The primary outcome was modified sofa scores at 96 hours and biomarkers.
I am not going to go over the secondary outcomes but there are 46 of them. They're covering ALL the bases! Good job.

They enrolled 167 patients. This is remarkable that they were able to enroll this many patients in these 7 centers from 9/14 until 11/17.

Results
Let's talk results. That's why you're here. Are you going to start giving vitamin C to your patients with ARDS, yes or no?

Primary outcome: mSOFA and biomarkers: NO DIFFERENCE.
Secondary outcomes: 43 of 46 had NO DIFFERENCE.

But here is the kicker. The three secondary outcomes that had a difference are pretty important.
1. All-cause mortality (p=0.03). 46.3% in the placebo group vs. 29.8% in the Vitamin C group
2. ICU-free days (p=0.03). Patients were transferred out of the ICU faster in the Vitamin C group
3. Hospital-free days (p=0.04) 22.6 in the vitamin C group vs 15.5 in the placebo

Think of all the money that could be saved by this inexpensive vitamin in shortening time in the hospital. $6 a dose, if I'm not mistaken.

No difference in the biomarkers? Well, this may be my off-kilter idea but maybe we are looking or do not full understand our biomarkers.

There were NO adverse effects that occurred during the trial! I've had many people talk about kidney stones, renal dysfunction, terrible side effects of vitamin C. Well, there were none.

Now, there are many limitations in this study. The authors admit to that full and well. Physicians like myself who are on the pro-vitamin C side will interpret the data the way I just did. Those who are contrarians on the matter will be able to look at the numbers and interpret it differently. They will point out all the flaws in the study and throw the findings of the endpoints in the trash. I may be completely off base with my interpretation of these results, but I want to do EVERYTHING that's reasonable to take care of my patients. And if that means spending $24 a day on Vitamin C, I will do it.

If you were the patients on the ventilator with ARDS, would you want the doctor treating you to give you vitamin C?

-EJ




Link to Abstract

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.