Welcome to the 114th 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
Andrews PJ et al Eurotherm3235 Trial Collaborators. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. NEJM 2015; 373:2403-2412. PMID: 26444221
- The Eurotherm3235 Trial is the largest international multicentre, prospective, randomised controlled study to date comparing hypothermia with standard care to standard care alone for intracranial hypertension in closed TBI patients. Even though this intervention did successfully reduce intracranial pressure it did not result in outcomes better than those with standard care alone. The trial was stopped early at the advice of the data and safety monitoring committee due to safety concerns, which introduces the risk of bias, but the results do suggest that outcomes were worse with hypothermia than with standard care alone. Other concerns with this trial were the inability to blind to the intervention and the large volume of cold saline used to induce hypothermia. This trial was an additional nail in hypothermia’s coffin.
- Recommended by: Nudrat Rashid
- Read More: Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. (SNACC)
de Lange DW et al. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol. 2013;51:385-393. PMID: 23697460
- Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used for refractory respiratory failure, while veno-arterial (VA) ECMO is used for refractory cardiopulmonary failure. Indications for VV ECMO have included severe ARDS and status asthmaticus, and VA ECMO has been used after massive MI and poisoning by cardiotoxic drugs. This article reviews techniques, indications, contraindications and complications of VV and VA ECMO. A literature review of ECMO in poisoned patients is also included.
- Recommended by: Meghan Spyres
Madhuri S. Kurdi et al. Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res 2014; 8(3): 283–290. PMID: 25886322
- A nice review article on the use of ketamine in the field of anesthesia, pain, palliative care, intensive care and procedural sedation. Based on at quite extensive literature search this paper highlights Ketamine’s current evidence based use as well as newer clinical applications. For instance a ketamine gargle attenuates postoperative sore throat!
- Recommended by: Søren Rudolph
Schmittinger CA et al. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38:950-8. PMID: 22527060
- What’s old is new again. There was a long of discussion around papers showing that patients who got more vigorous fluid resuscitations were more likely to die. Particularly in light of the ARISE / ProMISe/ ProCESS trilogy, this could be interpreted as showing that fluid resuscitation is bad, and we should instead use pressors. So I was fascinated when I came across this slightly old article. They looked 112 patients in a SICU on pressors. They carefully counted adverse events. Using exactly the same sort of analyses that have been purported to argue against fluid resuscitation, the authors showed that patients who got more pressors had a smooth dose response with more pressors leading to more adverse cardiac events, and patients with adverse cardiac events dying at much higher rates. If one believes that any useful evidence is provided by the articles showing more fluid is correlated with worse outcomes, then one must logically also believe that this article provides evidence that using pressors has the same bad effect. To those who cited those other articles as evidence to “Stop Drowning Our Patients”, then this one should be equally persuasive to stop pressor-ing them. I suspect, of course, that these associational articles show nothing of the sort. Instead they show what is termed “confounding by indication”. Patients who need more therapy often do so because either (a) they were sicker than originally thought (inadequate risk adjustment); or (b) because the therapy is administered after the risk adjustment measurements were made (usually on admission), and so receipt of the therapy provides information about physiology unavailable at the time of the original risk adjustment.
- Recommended by: Theodore J Iwashyna
Hagan AE et al. Sodium polystyrene sulfonate for the treatment of acute hyperkalemia: a retrospective study. Clin Nephrol. 2016; 85: 38-43. PMID: 26587776
- The utility of sodium polystyrene sulfonate (SPS) in the treatment of hyperkalemia is debatable. This retrospective chart review adds to the existing evidence of the disutility of treating acute hyperkalemia in the ED. In this study, the authors found a drop of about 1 mEq after administration of SPS at the next potassium check. However, the second check occurred at a median time of 8 hours after SPS administration. This change is hardly clinically relevant in life-threatening disease. Additionally, in there review of 500 patients, 2 patients developed colonic necrosis. The authors conclude that “SPS should not be routinely used as a treatment for acute hyperkalemia as it provided a decrease in serum potassium of less than 1.0 mEq/L within 8 hours, and its use is associated with serious adverse side effects.” Well said.
- Recommended by: Anand Swaminathan
- Read more: Myths in Emergency Medicine: Kayexalate for Hyperkalemia Unproven and Ineffective with One Mean Side Effect
Pemberton P et al. Is It Time to Beta Block the Septic Patient? Biomed Res Int 2015. PMID: 26557668
- I found this via Rob Macsweeney’s critical care reviews. This is a nice review article looking at some of the data andthe physiology behind the idea of beta blockers in sepsis. This was of course spurred by the Morelli trial (PMID 24108526) that showed a big drop in mortality with beta blocker use. They acknowledge the potential cardiovascular benefits of beta blockers in sepsis but they focus mainly on the immune modulating side of things.Who’d have thought that all the lymphoid organs are predominantly innervated by the sympathetic nervous system. It’s a nice read and it’s free too.
- Recommended by: Andy Neill