Neuromuscular Blockade Refresher

This review article from the World Federation of Societies of Anaesthesiologists is a great clinical review on Sugammadex and a good way to dust the cobwebs off your thinking about neuromuscular blockade and physiology.

Sugammadex Pic

From an ED point of view the use of Sugammadex is in the setting of modified RSI following the use of high-dose rocuronium to achieve similar intubating conditions as with regular RSI using suxamethonium.  If this type of modified RSI leads to a CICO scenario then the use of Sugammadex may be a salvage option.  It is an important drug of which to be aware – make sure you know its mechanism of action, indications in ED, dose, and potential side effects.

Sepsis 3 – the Death of SIRS?

The European Society of Intensive Care Medicine and The Society of Critical Care Medicine have redefined sepsis with their “Sepsis Rededinitions Task Force”.  This has been published in the most recent edition of JAMA.

There are still issues with the new definitions – can they be applied to all patients, do they apply to patient from low income areas, are the scoring tools relevant to Australian practice?  Regardless of this, it is a hot topic in critical care medicine and you need to be familiar with the new terms that you will soon hear being bandied about.

In summary:
1.  SIRS criteria are out the door
2.  Sepsis is now the presence of life-threatening organ dysfunction due to a dysregulated host response to infection
3.  Organ dysfunction is defined by a 2-point increase in the SOFA score (this is an ICU scoring system not commonly used in Australia)
4.  A modified version of this score (qSOFA) can be used at the bedside to identify those patients with a suspected infection who are at risk of a higher mortality – the score looks at conscious state, blood pressure, and resp rate
5.  Septic shock is now defined as hypotension where vasopressors are required to maintain MAP > 65mmHg AND a lactate level >2mmol/L

JAMA have kindly produced a brief explanatory video of the above info.

So, know the new terms, but don’t under-treat your next potential sepsis patient just because they don’t necessarily meet all the new criteria – clinical judgement still trumps at the moment.  Watch this space.

Heart Matters

A recent review article on advances in heart failure treatment from the Cleveland Clinic is a good reminder of the physiology behind traditional heart failure pharmacotherapy and a primer for emerging therapies – two of which are currently available in Australia, ivabradine (Coralan) and eplerenone (Inspra).

Being up to date with review articles such as this can really help when communicating with our cardiology colleagues.

Sweeter outcomes

How are we doing with our DKA management?  Probably pretty well according to recent article in Critical Care which looks at over 8000 DKA presentations to Australian and New Zealand ICUs from 2000 to 2013.

Overall presentations of DKA are up (fivefold!) but mortality has remained low and steady.  Reasons for the impressive increase in presentations include increasing incidence of DKA in the community, increased glucometer use, and increase in the number of certified rural and regional ICUs.

Over 80% of admissions to the ICU are from the emergency department.  Over the study period, there was an improvement in worst pH and worst bicarbonate in the first 24 hours of ICU stay over the time period studied – this may reflect better initial resuscitation and institution of DKA protocols in the ED.

Interestingly elevated urea levels were strongly independently associated with mortality.

This article is a good reminder of this common ED presentation with some fresh epidemiological info and perhaps a new marker of mortality (urea) to consider when you next treat a DKA patient in your ED.

Human Factors

After attending an airway workshop the other week, I thought it was appropriate to remind everyone of the Bromiley case and its impact on the approach to airway management along with the changes that Martin Bromiley has helped bring to the way we approach any airway case.

Martin Bromiley formed the Clinical Human Factors Group in 2007 to improve safety, quality, and productivity in healthcare.