R&R In The FASTLANE 134

Welcome to the 134th 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

Combes A, et al. Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study. Am J Respir Crit Care Med. 2015 Nov 15;192(10):1179-90. PMID: 26167637.

• This French prospective, multi-centre randomized controlled trial looked at patients with severe shock receiving high dose catecholamines within 3-24 hours after cardiac surgery. Patients were randomised to either conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury OR early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous veno-venous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function. The results did not show any difference in mortality or other patient centred outcomes between groups. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.
• Recommended by: Nudrat Rashid

Trac MH et al. Macrolide antibiotics and the risk of ventricular arrhythmia in older adults. CMAJ 2016; 188(7):E120-9. PMID: 26903359

• Do macrolides increase the risk of lethal cardiac dysrhythmias? This article is a large, population-based, retrospective cohort of adults > 65 years of age. It compares those who were prescribed a macrolide with those prescribed a non-macrolide antibiotic looking at the primary outcome of a presentation for a ventricular dysrhythmia at 30 days and a secondary outcome of all-cause mortality at 30 days. They found no difference. While it’s a suboptimal study methodology, this is further evidence that we need not fear these complications. But, this shouldn’t stop us from restricting treatment to only those who need it (i.e. don’t prescribe a Z-pack for a URI).
• Recommended by: Anand Swaminathan

ipkin DA, et al. Evidence-based risk communication: a systematic review. Annals of internal medicine. 161(4):270-80. 2014. PMID: 25133362

• Statistics are easily gamed and, are increasingly called upon as we engage patients in shared decision making, Communicating with patients – Think the number need to treat (NNT) is the best way? That’s not what this review found. They found that participants most accurately perceived risk when presented with absolute risk reduction but were most swayed by relative risk.
• Recommended by: Lauren Westafer

Zwaan L, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Quality & Safety. 2016. PMID: 26825476 

• Cognitive biases are a fun and sexy topic in medicine – I talk about them all the time. However, there is really no empiric evidence that teaching these biases or learning cognitive forcing strategies improves patient outcomes. This survey, based on clinical vignettes, indicated that physicians do not agree whether biases are present, and the assessment of bias is itself heavily influenced by hindsight bias. This is another small piece of the growing evidence that clinical decision making is incredibly complex and that simply identifying cognitive biases is unlikely to be a quick fix for diagnostic error.
• Recommended by: Justin Morgenstern

Levine M et al. “Systematic review of the effect of intravenous lipid emulsion therapy for non-local anesthetic toxicity.” Clin Tox 2016. PMID: 26852931

• Use of intravenous lipid emulsion (ILE) for non-local anesthetic drug toxicity is increasing, however evidence-based criteria for its use is still lacking. A workgroup was formed to review the effects of ILE in a systematic fashion. This is article provides a comprehensive summary of the literature in detailed tables broken down by substance, highlighting the log D for lipophilicity and clinical outcome. The workgroup underscores the overall low quality of evidence currently available, as well as heterogeneous outcomes reported after use of ILE in non-local anesthetic drug toxicity.
• Recommended by: Meghan Spyres

Studdert DM, et al. Prevalence and Characteristics of Physicians Prone to Malpractice Claims. N Engl J Med. 2016 Jan 28;374(4):354-362. PMID: 26816012.

• An interesting paper that examines the characteristics of malpractice claims in the United States. The authors used the National Practitioner Data Bank (NPDB) to obtain data on all payments made against MDs and DOs in a ten year period. Every practitioner in the NPDB has a unique identifier, allowing the authors to identify multiple claims against the same prover. By combing over the data, the authors found approximately 1% of all physicians accounted for 32% of paid claims in the time period. While limited in the study design, this large data analysis demonstrates a link between claims being paid out once and future payouts. Thought provoking and perhaps reassuring to the majority of physicians practicing? It also provides some foundational knowledge as the first step towards building a better liability system.
• Recommended by: Jeremy Fried