R&R In The FASTLANE 082

Welcome to the 82nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

TITRe2 Investigators. Liberal or Restrictive Transfusion after Cardiac Surgery. NEJM 2015; 372: 997-1008. PMID: 25760354

• This multicenter, parallel-group trial was conducted in multiple centres in the UK and recruited 2007 patients undergoing nonemergency cardiac surgery. Postoperatively patients with a haemoglobin of less than 9 g/dl were randomly assigned to a restrictive transfusion threshold (hemoglobin level <7.5 g/dl) or a liberal transfusion threshold (hemoglobin level <9 g/dl). No difference was shown in morbidity (serious infections or an ischaemic event) or health care costs (which were calculated from the day of surgery to 3 months after surgery) and differed from observational analyses of transfusion in patients undergoing cardiac surgery in the past. The only difference between groups was a higher 90-day mortality rate with the restrictive threshold at 4.2% versus 2.6% (hazard ratio 1.64%, P=0.045).  The attached editiorial is an interesting read.
• Recommended by: Nudrat Rashid
• Read More: Spertus J. “TITRe”ing the approach to transfusions after cardiac surgery. NEJM 2015; 372:1069-1070. PMID:25760360

Lacroix J et al. Age of transfused blood in critically ill adults. NEJM. 2015; 372(15): 1410-8. PMID: 25853745

• The ABLE study, in which 2340 ICU patients were randomized to receive fresh packed red cells (PRBCs) (<8 days) or standard blood (oldest compatible) adds more fuel to the fire showing that the old blood may not be associated with any deleterious clinical outcomes. The study was powered to detect a 5% difference in mortality but failed to find this as the “fresh” PRBC group had 37.0% mortality compared with 35.3% in the standard-blood group. Compliance with “fresh” and “standard” blood was reasonable good. Limitation: Most screened were excluded as they had already received PRBCs on that admission/ED visit.
• Recommended by: Lauren Westafer

Decker BS et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol. 2015. PMID: 25583292

• The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup was created to give evidence based recommendations for which poisonings should undergo hemodialysis. Though it is common teaching that lithium is dialyzable, there isn’t agreement on which patients should get dialyzed. This article outlines the EXTRIP workgroup’s recommendations based on their systematic review. Our focus should be on dialyzing patients with altered mentation, renal impairment and the presence of dysrhythmias.
• Recommended by: Anand Swaminathan
• Read More: Hemodialysis in lithium poisoning: what is the evidence? (The poison review)

Mismetti P et al. Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2015; 313(16): 1627-1635. PMID:25919526

• We all love studies that add support to what we always think: this RCT shows that IVC filters don’t really decrease rates of PE. Should help cut back on over-treatment?
• Recommended by: Seth Trueger

Kim NH et al. Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2013; 62: D92-9. PMID: 24355646 (FREE OPEN ACCESS ARTICLE)

• We’re very savvy with acute PE but I must confess to being less than knowledgable about chronic VTE. There’s not a great deal on clinical presentation here unfortunately but there is lots on diagnosis and management. Imaging of choice = V/Q and treatment of choice = endarterectomy.
• Recommended by: Andy Neill

Lavecchia M, Abenhaim HA. Cardiopulmonary resuscitation of pregnant women in the emergency department. Resuscitation 2015. PMID: 25625776.

• While obviously limited by the nature of the study’s design, these authors do provide those of us performing resuscitations important information on a population we (happily) rarely encounter: the pregnant woman undergoing CPR. They use administrative database information to compare the successful resuscitation rate between age matched pregnant and non-pregnant women and find a survival rate of 37% and 26%, respectively. The difference was driven by the gap in survival among non trauma patients with an OR of 2.10, and no difference found between pregnant and non pregnant patients when trauma was involved.
• Recommended by: Jeremy Fried