Arterial Monitoring in Hypertensive Emergencies: Significance for the Critical Care Resuscitation Unit.

INTRODUCTION: Blood pressure measurement is important for treating patients. It is known that there is a discrepancy between cuff blood pressure vs arterial blood pressure measurement. However few studies have explored the clinical significance of discrepancies between cuff (CPB) vs arterial blood pressure (ABP). Our study investigated whether differences in CBP and ABP led to change in management for patients with hypertensive emergencies and factors associated with this change. METHODS: This prospective observational study included adult patients admitted between January 2019-May 2021 to a resuscitation unit with hypertensive emergencies. We defined clinical significance of discrepancies as a discrepancy between CBP and ABP that resulted in change of clinical management. We used stepwise multivariable logistic regression to measure associations between clinical factors and outcomes. RESULTS: Of 212 patients we analyzed, 88 (42%) had change in management. Mean difference between CBP and ABP was 17 milligrams of mercury (SD 14). Increasing the existing rate of antihypertensive infusion occurred in 38 (44%) patients. Higher body mass index (odds ratio [OR] 1.04, 95% confidence Interval [CI] 1.0001-1.08, P-value <0.05) and history of peripheral arterial disease (OR 0.16, 95% CI 0.03-0.97, P-value <0.05) were factors associated with clinical significance of discrepancies. CONCLUSION: Approximately 40% of hypertensive emergencies had a clinical significance of discrepancy warranting management change when arterial blood pressure was initiated. Further studies are necessary to confirm our observations and to investigate the benefit-risk ratio of ABP monitoring.

Examining Predictors of Early Admission and Transfer to the Critical Care Resuscitation Unit.

INTRODUCTION: Previous studies have demonstrated that rapid transfer to definitive care improves the outcomes for many time-sensitive conditions. The critical care resuscitation unit (CCRU) improves the operations of the University of Maryland Medical Center (UMMC) by expediting the transfers and resuscitations for critically ill patients who exceed the resources at other facilities. In this study we investigated CCRU transfer patterns to determine patient characteristics and logistical factors that influence bed assignments and transfer to the CCRU. We hypothesized that CCRU physicians prioritize transfer for critically ill patients. Therefore, those patients would be transferred faster. METHODS: We performed a retrospective review of all non-traumatic adult patients transferred to the CCRU from other hospitals between January 1-December 31, 2018. The primary outcome was the interval from transfer request to CCRU bed assignment. The secondary outcome was the interval from transfer request to CCRU arrival. We used multivariate logistic regressions to determine associations with the outcomes of interest. RESULTS: A total of 1,741 patients were admitted to the CCRU during the 2018 calendar year. Of those patients, 1,422 were transferred from other facilities and were included in the final analysis. Patients' mean age was 57 ± 17 years with a median Sequential Organ Failure Assessment (SOFA) score of 3 [interquartile range 1-6]. Median time from transfer request to CCRU bed assignment was 8 (0-70) minutes. A total of 776 (55%) patients underwent surgical intervention after arrival. Using the median transfer request to bed assignment time, we found that patients requiring stroke neurology (odds ratio [OR] 5.49, 95% confidence interval [CI] 2.85-10.86), having higher SOFA score (OR 1.04, 95% CI 1.001-1.07), and needing an immediate operation (OR 2.85, 95% CI 1.98-4.13) were associated with immediate bed assignment time (≤8 minutes). Patients who were operated on (OR 0.74, 95% CI 0.55-0.99) were significantly less likely to have an immediate bed assignment time. CONCLUSION: The CCRU expedited the transfer of critically ill patients who needed urgent interventions from outside facilities. Higher SOFA scores and the need for urgent neurological or surgical intervention were associated with near-immediate CCRU bed assignment. Other institutions with similar models to the CCRU should perform studies to confirm our observations.

Transport of Peripartum Patients for Medical Management: Predictors of Any Intervention During Transport.

Background When obstetric patients present to a hospital without obstetric consultants for medical care, they are often transferred for a higher level of care. Factors associated with patient care during transport between hospitals are unknown. Our study investigated factors associated with care intensity. Methods We retrospectively reviewed charts from peripartum adult patients who were transported to our academic quaternary center between January 1, 2012, and April 19, 2020. We excluded patients transported for gynecologic or fetus-related complications. We defined any transport interventions as any ventilator management, any titration of continuous infusions, and any continuation or initiation of medication during transport. Results We included 126 patients, and the mean age (SD) was 29 (7) years. There were 87 (695) antepartum patients, with nine (7%) requiring mechanical ventilation. Of the patients, 98 (78%) received at least one intervention during transport. Transport time (OR: 1.03, 95% CI: 1.001-1.06, P = 0.040), preeclampsia (OR: 3.8, 95% CI: 1.1-12.7, P = 0.030), and any obstetric hemorrhage (OR: 8.3, 95% CI: 1.03-68, P = 0.047), either antepartum or postpartum, were associated with higher likelihood of receiving any intervention. Conclusions Peripartum patients often received interventions during transport. Preeclampsia and hemorrhage were associated with the likelihood of interventions. Transport clinicians should be prepared when transporting these patients. Further studies are needed to confirm our observations.

Effect of Blood Pressure Variability on Outcomes in Emergency Patients with Intracranial Hemorrhage.

INTRODUCTION: Patients with spontaneous intracranial hemorrhage (sICH) have high mortality and morbidity, which are associated with blood pressure variability. Additionally, blood pressure variability is associated with acute kidney injury (AKI) in critically ill patients, but its association with sICH patients in emergency departments (ED) is unclear. Our study investigated the association between blood pressure variability in the ED and the risk of developing AKI during sICH patients' hospital stay. METHODS: We retrospectively analyzed patients with sICH, including those with subarachnoid and intraparenchymal hemorrhage, who were admitted from any ED and who received an external ventricular drain at our academic center. Patients were identified by the International Classification of Diseases, Ninth Revision (ICD-9). Outcomes were the development of AKI, mortality, and being discharged home. We performed multivariable logistic regressions to measure the association of clinical factors and interventions with outcomes. RESULTS: We analyzed the records of 259 patients: 71 (27%) patients developed AKI, and 59 (23%) patients died. Mean age (± standard deviation [SD]) was 58 (14) years, and 150 (58%) were female. Patients with AKI had significantly higher blood pressure variability than patients without AKI. Each millimeter of mercury increment in one component of blood pressure variability, SD in systolic blood pressure (SBPSD), was significantly associated with 2% increased likelihood of developing AKI (odds ratio [OR] 1.02, 95% confidence interval [CI], 1.005-1.03, p = 0.007). Initiating nicardipine infusion in the ED (OR 0.35, 95% CI, 0.15-0.77, p = 0.01) was associated with lower odds of in-hospital mortality. No ED interventions or blood pressure variability components were associated with patients' likelihood to be discharged home. CONCLUSION: Our study suggests that greater SBPSD during patients' ED stay is associated with higher likelihood of AKI, while starting nicardipine infusion is associated with lower odds of in-hospital mortality. Further studies about interventions and outcomes of patients with sICH in the ED are needed to confirm our observations.

Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis.

BACKGROUND: Vasopressors are mainstay treatment for patients in shock and are usually infused through central venous catheters (CVCs). However, CVCs are associated with risk of infection or delay from the needs of confirmation of placement. Infusing vasopressor through peripheral venous catheter (PIVs) could be an alternative in the Emergency Departments (ED) but data regarding complications is inconclusive. We performed a random-effects meta-analysis to assess literature involving prevalence of complications from infusing vasopressors via PIVs. METHODS: We searched PubMed, EMBASE and Scopus databases from beginnings to 02/02/2020 to identify relevant randomized control trials, cohort, case-control studies. We excluded case reports. Authors assessed studies' quality with Newcastle-Ottawa Scale and Cochrane Risk of Bias tool. Kappa score was used to assess interrater agreement. Outcome was complications as direct results from infusing vasopressors through PIVs. RESULTS: We identified 325 articles and included 9 studies after reviewing 16 full text articles. Our analysis included 1835 patients whose mean age was 63 (Standard Deviation 12) years and 48% was female. There were 122 (7%) complications, of which 117 (96%) were minor. The meta-analysis with random effects showed the pooled prevalence of complications as 0.086 (95%CI 0.031-0.21). Studies reporting infusion safety guidelines had significantly lower prevalence of complications (0.029, 95%CI 0.018-0.045), compared to those not reporting a safety guideline (0.12, 95%CI 0.038-0.30, p = 0.024). CONCLUSION: There was low prevalence of complications as a direct result from infusing vasopressors through PIVs. Studies with safety guidelines were associated with significantly lower prevalence of complications. Further studies are needed to confirm our observations.

Blood pressure management in emergency department patients with spontaneous intracerebral hemorrhage.

INTRODUCTION: Despite the well documented importance of blood pressure management in patients with spontaneous intracerebral hemorrhage (sICH), little is known about whether emergency departments (EDs) are able to achieve close monitoring and precise management. Our study characterizes ED monitoring and management of blood pressure in sICH patients. METHODS: This is a retrospective study of adults with sICH and elevated intracranial pressure. Patients who were admitted from any referring ED to our CCRU from 1 August 2013 to 30 September 2015 were included. We graphically assessed the association between average minutes between blood pressure measurements and average minutes between administration of antihypertensives. We also performed logistic regression to evaluate factors associated with close blood pressure monitoring and the achievement of goal blood pressure in patients with sICH who presented with hypertension. RESULTS: Of 115 patients, 73 presented to the ED with SBP above 160 mmHg. Length of stay in the ED was significantly associated with a longer period between blood pressure measurements. Longer periods between blood pressure measurements were a significant determinant of failure to achieve blood pressure goal in sICH patients. Longer periods between blood pressure measurements were significantly associated with longer periods between administration of antihypertensives. CONCLUSION: Our study suggests that blood pressure monitoring is related to the frequency of blood pressure interventions and achievement of adequate blood pressure control in patients with sICH. There is significant variability in EDs' achievement of the recommended close blood pressure monitoring and management in patients with sICH.

Emergency and critical care providers' perception about the use of bedside ultrasound for confirmation of above-diaphragm central venous catheter placement.

INTRODUCTION: Chest radiography (CXR) is commonly used to confirm the proper placement of above-diaphragm central venous catheters (CVCs) and to detect associated complications. Recent studies have shown that point-of-care ultrasound (POCUS) has better sensitivity and is faster than CXR for these purposes. We were interested in documenting how often emergency medicine and critical care practitioners perform POCUS to confirm proper CVC positioning as well as their confidence in performing it. METHODS: We surveyed members of our state's chapters of the College of Emergency Physicians and the Society of Critical Care Medicine between April and December 2018. Our primary outcome was the percentage of providers who would agree to perform only POCUS, forgoing CXR, for confirmation of CVC position. We performed multivariable logistic regressions to measure associations between demographic, clinical information, and outcomes. RESULTS: One hundred thirty-six providers participated (a 25% participation rate). Their specialties were as follows: emergency medicine, 75%; critical care, 13%; and emergency medicine/critical care, 11%. Thirty-one percent would use POCUS only for CVC confirmation, while 42% were confident in performing POCUS for this purpose. Multivariable logistic regressions showed that performing more non-procedural ultrasound examinations was associated with a higher likelihood of agreeing to perform POCUS only (OR, 2.9; 95% CI: 1.3-6.3). Forty-six percent of relevant comments suggested more training to increase the use of POCUS. CONCLUSION: Participants in this study did not frequently use POCUS for CVC confirmation. Designers of training curricula should consider including more instruction in the use of POCUS to confirm proper CVC placement and to detect complications.

Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections.

BACKGROUND: Patients presenting to emergency departments with spontaneous anterior epistaxis may undergo anterior nasal packing and sometimes receive systemic prophylactic antibiotics. There has not been sufficient evidence to support or refute this practice. The main objective of this study was to compare the likelihood of clinically significant infection (CSI) between patients with or without prophylactic antibiotics for anterior nasal packing due to spontaneous epistaxis. METHODS: We performed a meta-analysis of the literature to assess whether prophylactic antibiotics prevented CSI among patients with anterior nasal packing by searching PubMed, Embase, and Scopus databases for original articles. We also looked at the secondary outcome of non-infectious complications. We reported the outcomes using random effect models. Human studies in English, randomized control trials, quasi-randomized trials, clinical trials, retrospective studies, and case series were included. We excluded studies involving patients undergoing otolaryngologic surgeries. Statistical heterogeneity was examined using the DerSimonian and Laird Q test and I2 statistic. RESULTS: A total of 281 articles were identified. Of these, 5 articles met inclusion criteria, with 383 patients receiving anterior nasal packing. One hundred sixty (42%) patients did not receive prophylactic antibiotics while 223 (58%) received antibiotics. The proportion of CSI in the pooled cohort was 0.8% (95% CI 0.2-1.9), resulting in a number needed to treat (NNT) to prevent one infection of 571. The rate of non-infectious complications associated with epistaxis was 20% (95% CI 10-32). CONCLUSIONS: This meta-analysis suggests that prescribing prophylactic antibiotics for anterior nasal packing may not be necessary due to the low proportion of CSIs across heterogenous patient populations. Further high-quality randomized trials are needed to support this finding.

Recreational 'mud fever': Leptospira interrogans induced diffuse alveolar hemorrhage and severe acute respiratory distress syndrome in a U.S. Navy seaman following 'mud-run' in Hawaii.

A 23-year-old man with a viral-like prodrome developed sudden severe dyspnea and was found to have renal failure, anemia, shock, and diffuse alveolar hemorrhage with acute respiratory distress syndrome, requiring emergent endotracheal intubation and extracorporeal membrane oxygenation (ECMO). Travel and exposure history from peripheral sources revealed that the patient had participated in a 'mud-run' in Hawaii two weeks prior to symptom onset. The patient was subsequently diagnosed with leptospirosis and treated with ceftriaxone and doxycycline. He was discharged on hospital day 13 with full recovery. Leptospirosis is associated with exposure to water, soil, or other matter contaminated with urine of carrier animals. It has been associated with a multitude of activities over time; most recently recreational water-based activities including 'mud-runs' in endemic areas have been added to the list of routes of exposure. This case underscores the importance of obtaining a thorough epidemiological exposure and travel history and being aware of areas of endemicity for life-threatening infections. Additionally, to our knowledge this is the second case of a patient in the United States treated with ECMO for leptospirosis induced pulmonary hemorrhage.

Loperamide induced cardiac arrhythmia successfully supported with veno-arterial ECMO (VA-ECMO), molecular adsorbent recirculating system (MARS) and continuous renal replacement therapy (CRRT).

Introduction: This case of Loperamide misuse had refractory ventricular arrhythmias and was successfully supported by VA ECMO. Loperamide is currently available without prescription and can be obtained in large quantities over the internet despite Food and Drug Administration (FDA) 2016 black box warning noting cardiac toxicity. This case illustrates the life-threatening toxicity of loperamide and suggests a supportive modality to provide clinical time while the drug is cleared endogenously or exogenously. Case report: A 36-year-old female was found minimally responsive. Vital signs and monitoring revealed wide complex bradycardia, undetectable blood pressure, hypothermia, bradypnea, and hypoglycemia. The rhythm degenerated to polymorphic ventricular tachycardia cardia refractory to multiple ACLS protocols. VA-ECMO was initiated with immediate stabilization. Subsequent history revealed massive consumption of loperamide taking 400-600 mg daily. Highest known loperamide and N-desmethyl-loperamide levels were 32 and 500 ng/ml respectively. Since loperamide and metabolites are known to be protein bound, molecular adsorbent recirculating system (MARS) was initiated for toxin clearance. Additionally, she developed acute renal failure supported by CRRT. She was ultimately weaned from ECMO, MARS, and CRRT and discharged neurologically intact on hospital day 12. Discussion: VA ECMO for hemodynamic support provided the needed time for natural resolution of the cardiac toxicity while providing adequate perfusion. MARS was used in the setting of highly protein bound toxins, but drug clearance could not be demonstrated through serial levels. VA ECMO (or referral to a center with VA ECMO) should be considered with lethal loperamide-induced cardiotoxicity and perhaps other cardio-toxins.