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ACP HospitalistWeekly 6-9-10

Highlights

• New guidelines and checklist on determining brain death
• Treating STEMI beyond recommended time increases mortality risk

Cardiology

• Post-heart attack hyperoxia associated with increased mortality

Critical care

• Replacing peripheral IV catheters routinely may not be necessary

FDA news

• PPIs get warning on fracture risk

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

From ACP Internist

• The next issue of ACP Internist is online

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Highlights

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New guidelines and checklist on determining brain death

The American Academy of Neurology has issued updated guidelines for determining brain death in adults, and a related checklist.

The guidelines, updated from 1995, take into account recent studies on clinical determination of brain death. They stipulate three signs that a person's brain has stopped functioning: the person is comatose, and the cause of the coma is known; all brainstem reflexes have permanently stopped working; and breathing has permanently stopped such that a ventilator must be used to keep the body functioning. They also review the best way to demonstrate absence of breathing, and conclude that laboratory tests such as electroencephalogram (EEG) or cerebral flow studies are not needed for a diagnosis, although they can be used when uncertainty exists with the neurologic exam or when the apnea test cannot be performed. A summary statement of the guidelines is published in the June 8 Neurology. A full copy of the guidelines update is available via the American Academy of Neurology Web site.

The guidelines note that complex-spontaneous motor movements and false-positive triggering of a ventilator can occur in brain-dead patients. Also, there isn't enough evidence to determine the minimally acceptable observation period for ensuring neurologic function has irreversibly stopped, nor is there enough evidence to determine if newer ancillary tests confirm the whole brain has stopped functioning.

“The brain death diagnosis can be made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments,” said lead guideline author Eelco Wijdicks, FACP, from the Mayo Clinic in Rochester, Minn., in a press release. "The new guideline includes a checklist that will help doctors with this diagnosis.”

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Treating STEMI beyond recommended time increases mortality risk

Treating ST-elevation myocardial infarction (STEMI) patients with reperfusion therapy beyond the recommended treatment times may increase mortality and readmission risk, a new study found.

Treatment guidelines specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI) for STEMI patients. Researchers evaluated care for 1,832 STEMI patients treated with reperfusion during a six-month period in 2006-2007 in 80 hospitals in Quebec, Canada. Main outcome measures were death at 30 days and one year, and a combined end point of death or hospital readmission for acute myocardial infarction (MI) or congestive heart failure at one year. Results were published June 2 in the Journal of the American Medical Association.

Twenty-one percent of patients (n=392) received fibrinolysis and 79% (n=1,440) received PPCI. Fibrinolysis was untimely (given after more than 30 minutes) in 54% of patients, and PPCI was untimely (given after 90 minutes) in 68% of patients. When the treatment groups were combined, patients treated beyond the recommended times had a higher adjusted risk of death at 30 days (6.6% vs. 3.3%; odds ratio [OR], 2.14; 95% CI, 1.21 to 3.93) than the patients who got timely treatment. Those treated beyond recommended times also had an adjusted higher risk for the combined outcome of death or hospital readmission for acute MI or congestive heart failure at one year (15% vs. 9.2%; OR, 1.57; 95% CI, 1.08 to 2.30).

The study is robust in that it represents "not a sampling, but 95% of STEMI patients within a large and complex system of care," the authors noted. It was also undertaken in a single-payer, universal access system, and thus associations aren't likely to be confounded by socioeconomic or insurance differences, they added. The association between longer treatment delay and poorer outcome may be confounded, they said, because patients who are sicker may be treated later; they may, for example, require more time to be hemodynamically stabilized. Overall, the findings suggest that time to reperfusion, rather than strategy, is more important for outcomes, which can help inform clinical decision making in the future, the authors said.

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Cardiology

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Post-heart attack hyperoxia associated with increased mortality

Hyperoxia is associated with higher in-hospital mortality compared to hypoxia or normoxia among patients admitted to intensive care units (ICUs) after resuscitation from cardiac arrest, researchers found.

Researchers conducted a multicenter cohort study using a critical care database of 131 U.S. hospitals between 2001 and 2005. The hospitals contributing to the study (n=120) comprised multiple types of ICUs and varied by size and geography.

Patient inclusion criteria were age 17 years or older, nontraumatic cardiac arrest, cardiopulmonary resuscitation within 24 hours prior to ICU arrival, and arterial blood gas analysis performed within 24 hours of arrival. Patients were categorized by the first arterial blood gas values obtained in the ICU: hyperoxia (PaO₂ of 300 mm Hg or greater), hypoxia (<60 mm Hg or ratio of PaO₂ to fraction of inspired oxygen <300), and normoxia (neither hyperoxia or hypoxia). Results appeared in the June 2 Journal of the American Medical Association.

Of 6,326 patients, 1,156 (18%) had hyperoxia, 3,999 (63%) had hypoxia, and 1,171 (19%) had normoxia. Overall, 56% of patients (n=3,561) died in the hospital. The hyperoxia group had significantly higher in-hospital mortality (732 of 1,156 [63%; 95% CI, 60% to 66%]) compared with the normoxia group (532 of 1,171 [45%; 95% CI, 43% to 48%]; proportion difference, 18% [95% CI, 14% to 22%; P<0.001]) and the hypoxia group (2297 of 3,999 [57%; 95% CI, 56% to 59%]; proportion difference, 6% [95% CI, 3% to 9%]; P<0.001). After researchers controlled for potential confounders such as age, preadmission functional status, comorbidity or vital signs, hyperoxia had an odds ratio (OR) for death of 1.8 (95% CI, 1.5 to 2.2).

Further, patients with hyperoxia were proportionally less likely to be discharged as functionally independent compared with patients with normoxia (29% vs. 38%, respectively; proportion difference, 9% [95% CI, 3% to 15%]; P=0.002). Multivariable logistic regression analysis factors significantly associated with in-hospital death included age, nonindependent functional status prior to admission, emergency department origin, active chemotherapy, chronic renal failure, hypotension on ICU arrival, tachycardia and hypoxia.

A secondary analysis that defined hyperoxia as PaO₂ of 400 mm Hg or greater found higher mortality (377 of 549; 69% [95% CI, 65% to 72%]) compared with the hypoxia group (2,297 of 3,999; 57% [95% CI, 56% to 59%]) and normoxia group (887 of 1,778; 50% [95% CI, 48% to 52%]). This hyperoxia group had significantly higher in-hospital mortality compared with the normoxia group (proportion difference, 19% [95% CI, 14% to 24%]; P<0.001). Mortality also was significantly higher in the hyperoxia group compared with the hypoxia group (proportion difference, 12% [95% CI, 8% to 16%]; P<0.001).

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Critical care

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Replacing peripheral IV catheters routinely may not be necessary

There is no conclusive evidence that changing peripheral intravenous (IV) catheters routinely reduces the risk of phlebitis and bacteremia, according to a new review.

The Centers for Disease Control and Prevention guidelines recommend replacing peripheral IV catheters every 72 to 96 hours, with an eye toward reducing bacteremia and phlebitis, the authors noted. To see if the measure is effective, they examined randomized controlled trials that compared routine removal with removal that occurred only when clinically indicated, in hospitalized or community-dwelling patients who were receiving intermittent or continuous infusions. Results were published in Issue 3, 2010 of the Cochrane Database of Systemic Reviews.

In five trials (3,408 subjects), there was a non-significant 44% reduction in suspected catheter-related bacteremia in the clinically indicated group (odds ratio [OR], 0.57; 95% CI, 0.17 to 1.94; P=0.37). In six trials (3,455 patients), there also was no significant difference in phlebitis between groups (9% for clinically indicated group vs. 7.2% for routine group; P=0.09). In addition, there was no difference in phlebitis incidence per 1,000 device days. In two trials (961 patients), cannulation costs were significantly lower in the clinically indicated group (mean difference, −6.21; 95% CI −9.32 to −3.11; P<0.000).

Given that the review found no conclusive evidence of benefit to routinely changing IV catheters, health care facilities may consider a policy of changing catheters only when it appears necessary. Not only would this provide cost savings, it "would also be welcomed by patients, who would be spared the unnecessary pain of routine re-sites in the absence of clinical indications," the authors wrote.

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FDA news

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PPIs get warning on fracture risk

High doses or long-term use of proton-pump inhibitors may increase the risk of certain fractures, the FDA recently warned health care professionals and patients.

The labeling of both prescription and over-the-counter PPIs will be revised to reflect this risk, according to an FDA news release. The warning is based on an FDA review of several epidemiological studies that reported an increased risk of fractures of the hip, wrist and spine in patients using PPIs.

Physicians should weigh the known benefits against the potential risks of proton-pump inhibitors when determining if these medications are appropriate for treatment, the FDA advised. “When prescribing proton pump inhibitors, health care professionals should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition,” said an FDA official.

Any side effects or other product problems with PPIs should be reported via the FDA’s MedWatch Adverse Event Reporting program or by calling 800-332-1088.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, 2010, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.

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From ACP Internist

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The next issue of ACP Internist is online

The June issue of ACP Internist features the following articles:

Internal Medicine 2010 coverage: Pearls aid treatment of opioid dependence
An expert reviews the benefits of agonist treatments over “going cold turkey,” how to foil abuse of oral medications, and the best way to nail inpatient diagnoses.

More conference coverage: Hospital medicine meeting offers advice for all internists
In addition to complete coverage of the American College of Physicians’ Internal Medicine meeting, readers can find coverage from the Society of Hospital Medicine’s annual meeting, including a digest of palliative care, consulting as a career and infectious disease control.

Practice Rx: DEA to ease burden, allow e-prescribing for controlled substances
The Drug Enforcement Administration has released an interim final rule allowing doctors to transmit prescriptions for controlled substances electronically. ACP’s practice management staff members outline how physicians can begin the process.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

 

 

 

 

 

 

 

 

"Odd ... it says here that your co-pay is an arm and a leg."

This issue's winning cartoon caption was submitted by Zac Erekson, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 142 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 53% of the votes.

The runners-up were:
"My HMO says I can be capitated here."
"You've lost weight, but that didn't really change your BMI."

ACP Hospitalist continues its cartoon caption contest this week. Pen the winning caption for the cartoon below and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

 

 

 

 

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated