R&R In The FASTLANE 099

Welcome to the 99th 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 5 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

Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015; 373(9):823-833. PMID: 26095867

• This randomized, double-blind, placebo-controlled trial assigned patients with chronic (permanent or paroxysmal) atrial fibrillation or flutter who had received warfarin therapy for 3 months or longer, with an international normalized ratio (INR) therapeutic range of 2.0 to 3.0 and were undergoing an elective operation or other elective invasive procedure that required interruption of warfarin therapy; and had at least one of the CHADS₂ stroke risk factors to receiving bridging anticoagulation therapy with dalteparin sodium (100 IU per kilogram of body weight administered subcutaneously twice daily) or to receive no bridging therapy (i.e., a matching subcutaneous placebo) from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. The results showed that  for this group of patients a strategy of forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism. The strategy of forgoing bridging treatment also decreased the risk of major bleeding.
• Recommended by: Nudrat Rashid

Del Portal DA, et al. Impact of an Opioid Prescribing Guideline in the Acute Care Setting. J Emerg Med 2015. PMID: 26281819

• As many EDs implement voluntary opioid prescribing guidelines, this study is the first of it’s kind to examine outcomes after doing so. The prescription opioid abuse epidemic in the U.S. is a well known problem and a black eye on the face of medicine as it’s an issue we created in an attempt to alleviate the suffering of our patients. Unfortunately, the pendulum clearly swung too far to the side of liberal distribution and we are now dealing with the consequences of over prescribing. The authors in this study detail their experience implementing a voluntary guideline at multiple ED sites. They found that opioid prescriptions for dental, neck, back, or unspecified chronic pain decreased from 52.7% before the guideline to 29.8% immediately after its introduction, and to 33.8% at an interval of 12 to 18 months later. Additionally, 100% of ED faculty supported the guideline. Importantly, providers were able to ʺoverrideʺ the guideline at their discretion and a state prescription monitoring database was not available at the time of the study.
• Recommended by: Jeremy Fried

Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin ‘‘allergy’’ in hospitalized patients: A cohort study. J Allergy Clin Immunol.  2014;133(3):790-6. PMID: 24188976

• Allergy to penicillin class drugs is extremely common. However, most studies show that only 1-5% of patients who claim an allergy actually have one. This article investigates the additional costs that occur as a result of penicillin ʺallergyʺ being placed on a chart. In this observational study, the authors found that patients had longer hospitalizations and at more risk for C.diff, MRSA and VRE infections. Overall, they found that it would be much cheaper and more efficient to test every patient to try and establish true allergy (or more likely, absence of allergy) than to continue to spend health care dollars in this way.
• Recommended by: Anand Swaminathan

Murphy N et al. Gestation-specific D-dimer reference ranges: a cross-sectional study. Br J Obstet Gyn 2015; 122:(3)395-400. PMID: 24828148

• The workup of pregnant patients with possible pulmonary embolism is complicated because the beloved decision aids haven’t been validated for use in this population and we know d-dimer levels increase naturally during gestation. This study took a sample from healthy pregnant patients (n=760) at different stages of gestation. They found, unsurprisingly, that d-dimer increases with gestational age, congruent with limited prior literature. They propose a continuous increasing d-dimer in pregnancy. With PE experts such as Dr. Kline proposing gestation adjusted d-dimer, this is a research space to watch.
• Recommended by: Lauren Westafer

Bouhemad B et al Ultrasound for ʺlung monitoringʺ of ventilated patients. Anesthesiology 2015; 122(2):437-47. PMID 25501898

• The use of lung ultrasound (LUS) is ever expanding. Today we know several specific LUS patterns corresponding to lung pathology and for some of these we have couple specific treatments. However the problem with LUS has mostly been how to communicate findings between clinicians and to monitor these over time. This paper offers a scoring system to monitor degree of lung aeration over time and as response to specific treatments, ie PEEP and prone position, in the ventilated patient.
• Recommended by: Søren Rudolph