Welcome to the 158th 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
Carson JL, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016. PMID: 27732721.
- This is a must read article which may change your clinical practice. These clinical guidelines from the AABB are based on a large number of patients in multiple clinical trials:
- Restrictive RBC transfusion level of 7 g/dL is recommended for hemodynamically stable patients, even those who are critically ill.
- Restrictive RBC transfusion level of 8g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease.
- Patients should receive RBCs selected at any point in their licensed dating period. There is no need to restrict patients to the use of “fresh” (<10 day) units.
- Importantly, the authors remind us that: “When deciding to transfuse an individual patient, it is good practice to consider not only the hemoglobin level, but the overall clinical context and alternative therapies to transfusion. Variables to take into consideration include the rate of decline in hemoglobin level, intravascular volume status, shortness of breath, exercise tolerance, lightheadedness, chest pain thought to be cardiac in origin, hypotension or tachycardia unresponsive to fluid challenge, and patient preferences.”
- Recommended by Jeremy Fried
Marik PE. Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation. Crit Care Med 2016. PMID: 26571187
- Fluid resuscitation is a critical skill for resuscitationists and critical care docs but do we truly understand the fundamental principles? This brief article from Paul Marik is a must read on the topic that delves into why fluid resuscitation works (or doesn’t), how to gauge responsiveness and CVP.
- Recommended by Anand Swaminathan
Tankel AS et al. The VHOT (Vindaloo Hastens Outpouring of Troponins) Study. Emerg Med Australas 2016. PMID: 27701829
- Is that spicy chicken vindaloo going to cause your troponin to bump? These researchers asked the question that was clearly on everyones mind: does spicy food cause troponinitis? Alright, I’ve never asked this question but good to know that at least in healthy volunteers, this isn’t an issue. So go ahead and eat the vindaloo and know that your heart is probably gonna be okay.
- Recommended by Anand Swaminathan
McEwan A, Silverberg JZ. Palliative Care in the Emergency Department. Emergency medicine clinics of North America 2016. PMID: 27475020
- This is an excellent read that can’t really be summarized in a few sentences. If you ever struggle with communicating with patients about the end of life, put this paper in your “to read” file.
- Recommended by Justin Morgenstern
Kalil AC, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases 2016. PMID: 27418577
- The IDSA released new guidelines for treatment of ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP) in July. Healthcare-associated pneumonia (HCAP) has been done away with, as there was a lower risk for multi-drug resistant pathogens than expected in the HCAP population. Here is the gist of this 51 page document:
- Invasive cultures aren’t needed.
- Biomarkers are out, like procalcitonin and CRP.
- Empiric treatment should be guided by local hospital resistance patterns.
- VAP should include MRSA coverage if >10% methicillin resistance rate and should only double cover for gram-negatives, i.e. pseudomonas, if at risk for multi-drug resistant organism or >10% gram-negative resistance rates.
- Treatment should be for 7 days, not 15.
- There are several other recommendations regarding dosing and specific pathogens that are not as directly applicable to the ED.
- Recommended by Clay Smith
- Read more: HCAP is out: New IDSA guidelines for HAP and VAP (EM Topics)