R&R In The FASTLANE 116

Welcome to the 116th 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

Doig et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med 2015; 3(12):943-52 PMID:26597128

• This randomised, multicentre, single-blind clinical trial was conducted in 13 hospital intensive care units (ICUs) in Australia and New Zealand to assess whether energy restriction affects the duration of critical illness, and other measures of morbidity, compared with standard care. 339 adult critically ill patients who developed refeeding syndrome within 72 h of commencing nutritional support in the ICU were enrolled. The results showed that protocolised caloric restriction is a suitable therapeutic option for critically ill adults who develop refeeding syndrome with the protocolised caloric restriction group also showing improved  key individual components of the primary outcome: more patients were alive at day 60 and overall survival time was increased.
• Recommended by: Nudrat Rashid

Kalil A et al. Association Between Vancomycin Minimum Inhibitory Concentration and Mortality Among Patients With Staphylococcus aureus Bloodstream Infections A Systematic Review and Meta-analysis. JAMA 2014; 312(15):1552-64. PMID: 25321910

• Vancomycin is a commonly used antibiotic for the treatment of staphylococcal infections, particularly for MRSA. Alternate drugs active against MRSA may be employed if culture and sensitivity findings identify a high minimal inhibitory concentration (MIC). However, this article finds that the finding of a high MIC does not necessarily mean that vancomycin will not be effective in treating the infection. This article raises the question of how important MIC is and whether we should be developing and testing alternate ways to assess antibiotic efficacy.
• Recommended by: Anand Swaminathan

Piazza G et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv 2015; 24;8(10):1382-92. PMID: 26315743

• This is simple prospective data on a highly selected group of patients with massive or sub massive PEs. There were almost as many authors as patients here… You got into the trial based on the CT signs of severity. They allowed up to 14 days of symptoms prior to enrolment which seems a tad long. The intervention here was a device with tpa into the clot itself. All got heparin too. The idea is that you only get 1mg/hr of tpa so the dose is tiny and much better directed. Primary outcome was lots of surrogate end point stuff – important but not really what we want to know They ended up with 160 pts (80% sub massive, 20% massive) and everyone did great. 3% overall mortality. All the numbers and even the repeat CTPA (!!!) got better. It does seem relatively safe and there no head bleeds in 160 pts. The bigger question is can we get the same good outcomes without having to do this? Does improving the numbers make the actual patient better. We’ll have to wait for that study…
• Recommended by: Andy Neill

Crosson JE, Nies M. Brugada syndrome in children. Expert Rev Cardiovasc Ther 2015;13(2):173-81. PMID: 25583159

• Syncope is common in kids. It is also usually not a big deal, but before we pat the kid on the head and reassure the parents, let’s consider some potentially lethal causes… like Brugada! Yup… it happens in kids too.
• Recommended by: Sean Fox
• Read More: Brugada in Children (Pediatric EM Morsels)

Bernhard M et al. The First Shot Is Often the Best Shot: First-PassIntubation Success in Emergency Airway Management. Anest analg. Anesth Analg. 2015; 121(5):1389-93. PMID 26484464

• The First Shot Is Often the Best Shot ! This is the mantra of anesthetists, but is there evidence to support this argument? In this paper the the authors review the literature with respect to the concept of first-pass intubation success, intubation success rates for physicians and nonphysician providers, and the impact of training on first-pass and overall pass success rates. Eight studies demonstrating an association between multiple in-hospital and prehospital intubation attempts and complications were identified after a thorough litterature search. Multiple attempts at intubation increase complication (risk of hypoxemia, esophageal intubation, aspiration, and cardiac arrest) rates with odds ratios between 4,7-7,5. Data from also indicate that first-pass success rates differ by provider type. First-pass success rates ranged from 46.4% to 77.2% for paramedics, 71.2% to 87.5% for prehospital physicians, and 60.7% to 97.3% for in-hospital physicians. Evidence also suggests that training improves first-pass success rates.
• Recommended by: Søren Rudolph

Isacson D et al. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. Int J of Colorectal Disease. 30(9):1229-34. 2015. PMID: 25989930

• Do antibiotics really help diverticulitis? In a prior R&R, we noted an RCT that illustrated no benefit of antibiotics over placebo. This is a prospective observational trial that followed 155 adult patients with acute, uncomplicated diverticulitis who did not receive antibiotics. Only 4 patients (2.5%) failed this outpatient management strategy – similar to what you would expect with antibiotics. Patients weren’t consecutive and there was no comparison group – but still, 97.5% of patients were perfectly fine without antibiotics.
• Recommended by: Justin Morgenstern