Welcome to the 178th 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
Costa Leme A, Hajjar LA, et al. Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial. JAMA. 2017. PMID: 28322416
- This single centre randomised control trial was conducted in an ICU in Brazil and looked at the benefit of applying a more intensive alveolar recruitment strategies in post-operative hypoxaemic cardiac surgical patients who were already receiving peri-operative small tidal volumes and lung protective ventilation. Less severe pulmonary complications while in the hospital were observed in the group that received the intensive alveolar recruitment strategy.
- Recommended by: Nudrat Rashid
- Further reading: Optimizing the Settings on the Ventilator Settings, High PEEP for All? (JAMA Editorial)
Bray JE, et al. Changing target temperature from 33 ◦C to 36 ◦C in the ICU management of out-of-hospital cardiac arrest: A before and after study. Resuscitation 2017. PMID: 28159575
- Do patients need therapeutic hypothermia with a target of 32-34 degrees after ROSC without RONF? Recent trials say no but the effect of changing the target temperature to 36 degrees is unknown . . . until now. This retrospective study found that when the goal was set to 36 degrees, patients were more likely to NOT meet their target temperature, to have fevers and there was a suggestion of increased poor outcomes. There are some differences between groups which limits the findings but these findings are concerning.
- Recommended by: Anand Swaminathan
Skoog CA, Engebretsen KM. Are vasopressors useful in toxin-induced cardiogenic shock? Clin Toxicol 2017. PMID: 28152638
- The management of toxin-induced cardiogenic shock is controversial with some groups favoring the use of high dose insulin (HIE) and others favoring use of vasopressors. This thoughtful retrospective review including both human case reports and controlled animal data found that use of vasopressors for toxin-induced shock was ineffective (but not harmful) in humans and potentially harmful in animals. Although most human cases survived, lack of efficacy was determined by reported hemodynamic response to vasopressors in the case reports. The use of multiple agents in many cases inherently limited the efficacy score. Proponents of vasopressors (see post on Levine article) would argue that observed lack of efficacy is often due to under dosing of vasopressors. In the absence of a large RCT, this debate will likely remain unresolved. Perhaps judicious use of all available options on a case by case basis is the best current approach.
- Recommended by: Meghan Spyres
Durant E, et al. Ultrasound-guided serratus plane block for ED rib fracture pain control. Am J Emerg Med. 2017. PMID: 27595172
- I love a good nerve block. In the past few years i’ve tried to do them more and more. This is a simple 2 patient case series of using the “serratus plane block” for control of rib fracture pain. I was always told that thoracic epidural was the only way to go and that seemed outside my skill set. This technique is akin to the fascia iliaca block that we’re all much more used to and in these 2 patients it seemed to work well. Worth considering. H/T to Sergey Motov who tweeted the paper.
- Recommended by: Andy Neill
Aprahamian CJ, et al. Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care. J Pediatr Surg. 2016. PMID: 28069270
- We perform I&D often, but is there a better way to do it? Particularly when we are dealing with children, we have to not only consider the initial incision and drainage, but also the repeat evaluations and packing changes which can be just as traumatic. The Loop Drainage method can help alleviate that need for repeat packing changes and also uses smaller incisions – two good things.
- Recommended by: Sean M. Fox