Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome.

BACKGROUND: Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function. OBJECTIVES: To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022. SELECTION CRITERIA: We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist. DATA COLLECTION AND ANALYSIS: Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome. MAIN RESULTS: We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard. AUTHORS' CONCLUSIONS: The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

Comparison of artificial intelligence versus real-time physician assessment of pulmonary edema with lung ultrasound.

BACKGROUND: Lung ultrasound can evaluate for pulmonary edema, but data suggest moderate inter-rater reliability among users. Artificial intelligence (AI) has been proposed as a model to increase the accuracy of B line interpretation. Early data suggest a benefit among more novice users, but data are limited among average residency-trained physicians. The objective of this study was to compare the accuracy of AI versus real-time physician assessment for B lines. METHODS: This was a prospective, observational study of adult Emergency Department patients presenting with suspected pulmonary edema. We excluded patients with active COVID-19 or interstitial lung disease. A physician performed thoracic ultrasound using the 12-zone technique. The physician recorded a video clip in each zone and provided an interpretation of positive (≥3 B lines or a wide, dense B line) or negative (<3 B lines and the absence of a wide, dense B line) for pulmonary edema based upon the real-time assessment. A research assistant then utilized the AI program to analyze the same saved clip to determine if it was positive versus negative for pulmonary edema. The physician sonographer was blinded to this assessment. The video clips were then reviewed independently by two expert physician sonographers (ultrasound leaders with >10,000 prior ultrasound image reviews) who were blinded to the AI and initial determinations. The experts reviewed all discordant values and reached consensus on whether the field (i.e., the area of lung between two adjacent ribs) was positive or negative using the same criteria as defined above, which served as the gold standard. RESULTS: 71 patients were included in the study (56.3% female; mean BMI: 33.4 [95% CI 30.6-36.2]), with 88.3% (752/852) of lung fields being of adequate quality for assessment. Overall, 36.1% of lung fields were positive for pulmonary edema. The physician was 96.7% (95% CI 93.8%-98.5%) sensitive and 79.1% (95% CI 75.1%-82.6%) specific. The AI software was 95.6% (95% CI 92.4%-97.7%) sensitive and 64.1% (95% CI 59.8%-68.5%) specific. CONCLUSION: Both the physician and AI software were highly sensitive, though the physician was more specific. Future research should identify which factors are associated with increased diagnostic accuracy.

The integrative feedback tool: assessing a novel feedback tool among emergency medicine residents.

OBJECTIVE: Feedback is critical to the growth of learners. However, feedback quality can be variable in practice. Most feedback tools are generic, with few targeting emergency medicine. We created a feedback tool designed for emergency medicine residents, and this study aimed to evaluate the effectiveness of this tool. METHODS: This was a single-center, prospective cohort study comparing feedback quality before and after introducing a novel feedback tool. Residents and faculty completed a survey after each shift assessing feedback quality, feedback time, and the number of feedback episodes. Feedback quality was assessed using a composite score from seven questions, which were each scored 1 to 5 points (minimum total score, 7 points; maximum, 35 points). Preintervention and postintervention data were analyzed using a mixed-effects model that took into account the correlation of random effects between study participants. RESULTS: Residents completed 182 surveys and faculty members completed 158 surveys. The use of the tool was associated with improved consistency in the summative score of effective feedback attributes as assessed by residents (P=0.040) but not by faculty (P=0.259). However, most of the individual scores for attributes of good feedback did not reach statistical significance. With the tool, residents perceived that faculty spent more time providing feedback (P=0.040) and that the delivery of feedback was more ongoing throughout the shift (P=0.020). Faculty felt that the tool allowed for more ongoing feedback (P=0.002), with no perceived increase in the time spent delivering feedback (P=0.833). CONCLUSION: The use of a dedicated tool may help educators provide more meaningful and frequent feedback without impacting the perceived required time needed to provide feedback.

Diagnostic accuracy of ultrasound to confirm endotracheal tube depth.

INTRODUCTION: Endotracheal intubation is commonly performed in the Emergency Department. Traditional measures for estimating and confirming the endotracheal tube (ETT) depth may be inaccurate or lead to delayed recognition. Ultrasound may offer a rapid tool to confirm ETT depth at the bedside. METHODS: This was a randomized trial assessing the diagnostic accuracy of ultrasound to confirm ETT depth. Three cadavers were intubated in a random sequence with the ETT placed high (directly below the vocal cords), middle (2 cm above the carina), or deep (ETT at the carina). Seven blinded sonographers assessed the depth of the ETT using ultrasound. Outcomes included diagnostic accuracy of sonographer identification, time to identification, and operator confidence based upon ETT location. A subgroup analysis was performed to assess diagnostic accuracy by operator confidence. RESULTS: 441 total assessments were performed (154 high, 154 middle, and 133 deep ETT placements). Overall accuracy was 84.8% (95% CI 81.1% to 88.0%). When placed high, ultrasound was 82.5% sensitive (95% CI 75.5% to 88.1%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 15.3 s (95% CI 13.6-17.0) and a mean operator confidence of 3.9/5.0 (95% CI 3.7-4.1). When the ETT was placed in the middle, ultrasound was 83.8% sensitive (95% CI 77.0% to 89.2%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 16.7 s (95% CI 14.6-18.8) and a mean operator confidence of 3.7/5.0 (95% CI 3.5-3.9). When the ETT was placed deep, ultrasound was 88.0% sensitive (95% CI 81.2% to 93.0%) and 92.2% specific (95% CI 88.6% to 94.6%) with a mean time to identification of 19.0 s (95% CI 17.3-20.7) and a mean operator confidence of 3.4/5.0 (95% CI 3.2-3.6). Sonographers were significantly more accurate when they reported a higher confidence score. CONCLUSION: Ultrasound was moderately accurate for identifying the ETT location in a cadaveric model and was more accurate when sonographers felt confident with their visualization. Future research should determine the accuracy of combining transtracheal ultrasound with lung sliding and other modifications to improve the accuracy.

Covered or uncovered: A randomized control trial of Tegaderm versus no Tegaderm for ocular ultrasound.

BACKGROUND: Studies on ocular point-of-care ultrasound vary on whether gel should be directly applied to the eye or on top of an adhesive membrane (i.e., Tegaderm™). However, there are currently no data regarding which approach has better image quality and the impact of patient preference. In this study, we sought to address this gap by assessing the difference in image quality and patient preference between Tegaderm™ versus no Tegaderm™ for ocular ultrasound in the emergency department. METHODS: Patients were randomized to have a Tegaderm™ placed on either their right or left eye. The other eye served as a comparator with no Tegaderm™. Ultrasound was performed on the right eye followed by the left eye in all instances. After performing each ultrasound, the sonographer asked the patient to rate their maximal discomfort from the ultrasound of that eye using a Likert scale (0 = no discomfort; 10 = severe discomfort). The sonographer then asked the patient which side (Tegaderm™ vs no Tegaderm™) they preferred. Finally, images were reviewed by an experienced ultrasound fellowship-trained sonographer blinded to allocation and rated from 1 to 5. Continuous data were analyzed using descriptive statistics with mean and standard deviation. A paired samples t-test was performed to assess for differences between groups. Categorical data were presented as frequency and percentage. RESULTS: The mean image score was significantly worse with Tegaderm™ compared with no Tegaderm™ (mean difference: 0.94/5.00; 95% CI 0.79-1.08; p < 0.001). This was consistent in both the transverse and the sagittal plane subgroups. The percentage of acceptable images was also higher in the no Tegaderm™ group compared with the Tegaderm™ group (97.8% versus 82.8%). There was no statistically significant difference in patient discomfort with the Tegaderm™ versus no Tegaderm™ group. When asked to compare the two approaches, 54.4% of patients preferred Tegaderm™, 30.0% preferred no Tegaderm™, and 15.6% had no preference. CONCLUSIONS: Tegaderm™ was associated with reduced image quality and no significant difference in patient discomfort when utilized for ocular ultrasound. This study suggests that ocular ultrasound may be better performed without the use of Tegaderm™. Future research should evaluate the impact of Tegaderm™ vs. no Tegaderm™ among more novice users.

Clinical outcomes after 4F-PCC for warfarin-associated ICH and baseline GCS less than or equal to 8.

PURPOSE: There is limited evidence describing the mortality benefit of utilizing 4-factor prothrombin complex concentrate (4F-PCC) in patients presenting with a warfarin-associated intracerebral hemorrhage (ICH) and a Glasgow Coma Scale (GCS) of ≤8. The aim of this study is to determine the potential mortality benefit of 4F-PCC in this patient population. METHODS: This was a retrospective chart review, performed at a comprehensive stroke center from October 2013 through August 2020. Patients were included if they were ≥ 18 years of age, experienced a spontaneous ICH with baseline GCS ≤ 8, treated with warfarin prior to admission, had a baseline INR ≥ 1.7, and received 4F-PCC for INR normalization due to warfarin-associated ICH. The primary outcome was in-hospital mortality at 30 days. RESULTS: A total of 252 patients received 4F-PCC in the specified time period. Of those patients, 25 patients met inclusion criteria. Sixteen patients (64%) experienced in-hospital mortality. When compared to a historical estimated 80% mortality rate in the studied patient population, there was no statistically significant difference (p = 0.208) in mortality when 4F-PCC was utilized to reverse INR. CONCLUSION: The administration of 4F-PCC in patients presenting with warfarin-related ICH and GCS ≤ 8 did not result in statistically significant mortality benefit. Our results are limited by study design and sample size. Thus, larger studies are needed to determine if a benefit exists for 4F-PCC in this patient population. Although the results are not statistically significant, our small study suggests that there may be a clinically significant mortality benefit when 4F-PCC is utilized.

Comparison of saline versus air for identifying endotracheal intubation with ultrasound.

INTRODUCTION: After intubation has been performed, it is important to rapidly confirm the correct location of the endotracheal tube (ETT). Multiple techniques have been described, each with different limitations. Ultrasound has been increasingly recognized as an alternate modality for identifying the ETT location. However, it can be challenging to visualize the air-filled ETT cuff. Saline insufflation of the ETT cuff has been suggested to improve visualization of the ETT but data are limited. Our study sought to compare the diagnostic accuracy of air versus saline ETT cuff inflation on the diagnostic accuracy of intubation. METHODS: This was a randomized trial comparing air versus saline cuff inflation using a cadaver model. Adult cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and air versus saline. Blinded sonographers assessed the location of the ETT using the static technique. Outcomes included accuracy of sonographer identification, time to identification, and operator confidence. RESULTS: 480 total assessments were performed. When using air, ultrasound was 95.8% sensitive (95% CI 90.5% to 98.6%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 8.5 s (95% CI 7.6 s to 9.4 s) and a mean operator confidence of 4.32/5.0 (95% CI 4.21 to 4.42). When using saline, ultrasound was 100% sensitive (95% CI 97.0% to 100%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 6.3 s (95% CI 5.9 s to 6.8 s) and a mean operator confidence of 4.52/5.0 (95% CI 4.44 to 4.60). CONCLUSION: There was no statistically significant difference between air versus saline for intubation confirmation. However, saline was associated with fewer false negatives. Additionally, time to confirmation was faster and operator confidence was higher with the saline group. Further studies should determine if the outcomes would change with more novice sonographers or in specific patient populations.

Prophylactic antiemetics for adults receiving intravenous opioids in the acute care setting.

BACKGROUND: Physicians often prescribe opioids for pain in the acute care setting. Nausea and vomiting are well-described adverse events, occurring in over one-third of patients. Prophylactic antiemetics may be one option to reduce opioid-associated nausea and vomiting. However, these medications also have their own adverse effects, so it is important to understand their efficacy and safety prior to routine use. This is a review of randomized controlled trials comparing prophylactic antiemetics versus placebo or standard care for preventing opioid-associated nausea and vomiting. OBJECTIVES: To assess the effects of prophylactic antiemetics for nausea and vomiting in adults (aged 16 years or older) receiving intravenous opioids in the acute care setting. SEARCH METHODS: We searched CENTRAL (the Cochrane Library), MEDLINE (OVID), Embase (OVID) from inception to January 2022, and Google Scholar (17 January 2022). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and screened reference lists. SELECTION CRITERIA: We included randomized controlled trials of prophylactic antiemetics versus placebo or standard care in adults prior to receiving an intravenous opioid. DATA COLLECTION AND ANALYSIS: Two review authors (MG, JNC) independently determined the eligibility of each study according to the inclusion criteria. Two review authors (MG, GDP) then independently extracted data, assessed risk of bias, and determined the certainty of evidence using GRADE. Our primary outcomes were the occurrence of nausea, vomiting, and adverse events. Secondary outcomes included nausea severity, number of vomiting episodes, and number of participants requiring antiemetic rescue therapy. We presented outcomes as risk ratios (RR) for dichotomous data (e.g. presence of vomiting, presence of nausea, number of participants requiring rescue medication, adverse events) and mean difference (MD) or standardized mean difference for continuous data (e.g. number of vomiting episodes, nausea severity) with 95% confidence intervals (CI). MAIN RESULTS: We included three studies involving 527 participants (187 women and 340 men) with a mean age of 42 years.  All studies used intravenous metoclopramide (10 mg) as the intervention and a placebo for the comparator. No studies assessed any other antiemetic or compared the intervention to standard care. Compared to placebo, metoclopramide did not reduce vomiting (RR 1.18, 95% CI 0.26 to 5.32; low-certainty evidence) or nausea (RR 0.55; 95% CI 0.15 to 2.03; low-certainty evidence) and there was no difference in adverse events (RR 2.34, 95% CI 0.47 to 11.61; low-certainty evidence).  No data were available regarding the number of vomiting episodes. Metoclopramide did reduce the severity of nausea compared with placebo (MD -0.49, 95% CI -0.75 to -0.23; low-certainty evidence) but did not reduce the need for rescue medication (RR 1.86, 95% CI 0.17 to 20.16; low-certainty evidence).  Two studies were at unclear risk of bias for random sequence generation, one for blinding of outcome assessors, one for incomplete outcome data, and two for selective reporting. The studies were at low risk of bias for all remaining components. AUTHORS' CONCLUSIONS: There was no evidence that prophylactic metoclopramide affected the risk of vomiting, nausea, or the need for rescue medication when provided prior to intravenous opioids in the acute care setting. There was a clinically insignificant difference in nausea severity when comparing prophylactic metoclopramide with placebo. Overall, the evidence was of low certainty. Future research could better delineate the effects of prophylactic antiemetics on specific populations, and new studies are needed to evaluate the use of other prophylactic antiemetic agents, for which there were no data.

Ultrasound for the diagnosis of shoulder dislocation and reduction: A systematic review and meta-analysis.

BACKGROUND: Shoulder dislocations are a common injury prompting presentation to the emergency department. Point-of-care ultrasound (POCUS) is a diagnostic tool for shoulder dislocations, which has the potential to reduce time to diagnosis and reduction, radiation exposure, and health care costs. This systematic review sought to evaluate the diagnostic accuracy of POCUS for diagnosing shoulder dislocations. METHODS: We searched PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles for all prospective and randomized controlled trials evaluating the diagnostic accuracy of POCUS for identifying shoulder dislocations. We dual-extracted data into a predefined worksheet and performed quality analysis using the QUADAS-2 tool. We performed a meta-analysis with subgroup analyses by technique and transducer type. As a secondary outcome, we assessed the diagnostic accuracy of identifying associated fractures. RESULTS: Ten studies met our inclusion criteria, comprising 1,836 assessments with 636 dislocations (34.6%). Overall, POCUS was 100% (95% confidence interval [CI], 85.6%-100%) sensitive and 100% (95% CI, 79.4%-100%) specific for the diagnosis of shoulder dislocation with a LR+ of 11,254.8 (95% CI, 3.9-3.3e7) and a LR- of <0.1 (95% CI, < 0.1-0.2). When compared with the anterior/lateral technique, the posterior technique had greater sensitivity but no difference in specificity. There was no difference between transducer types. POCUS was also 96.8% (95% CI, 92.6%-98.7%) sensitive and 99.7% (95% CI, 92.5%-100%) specific for the diagnosis of associated fractures. CONCLUSIONS: POCUS is a sensitive and specific tool for the rapid identification of shoulder dislocations and reductions, as well as for the detection of associated fractures. POCUS should be considered as an alternate diagnostic tool for the diagnosis and management of shoulder dislocations.

Impact of Prior-to-Admission Methicillin-Resistant Staphylococcus aureus Nares Screening in Critically Ill Adults With Pneumonia.

BACKGROUND: The high negative predictive value (NPV) of a negative nasal methicillin-resistant Staphylococcus aureus (MRSA) result in suspected MRSA pneumonia is well established; however, data are limited on the NPV of samples collected prior to hospital admission for critically ill patients. OBJECTIVE: To evaluate the predictive characteristics of MRSA nares screening performed prior to hospital admission in critically ill adult patients diagnosed with pneumonia. METHODS: A retrospective analysis was conducted in critically ill patients with pneumonia and MRSA nares screening within 60 days of respiratory culture. The primary outcome was NPV of MRSA nares for MRSA pneumonia using samples within 60 days compared to in-hospital respiratory cultures. A sensitivity analysis was performed for samples within 30 days. Secondary outcomes were prevalence, positive predictive value (PPV), sensitivity, specificity, and MRSA pneumonia risk factors. RESULTS: The NPV for MRSA nares screening collected prior to hospital admission was high at 98% (95% CI = 96%-99%) for samples collected within 60 days (n = 243) and 99% (95% CI: 94%-99.9%) for samples within 30 days (n = 119). Specificity for MRSA nares collected 60 days prior to admission (96%, 95% CI: 93-98) and 30 days (96%, 95% CI: 91%-99%) were both high. PPV and sensitivity were lower. Risk factors for MRSA pneumonia were similar. CONCLUSION AND RELEVANCE: MRSA nares screening within 60 days of intensive care unit admission has a high NPV and specificity for MRSA pneumonia in critically ill patients and may be a powerful stewardship tool for avoidance of empirical anti-MRSA therapy.

Under the Microscope: A Look Into the Role of Critical Care Pharmacists During the COVID-19 Pandemic.

Among disciplines, the COVID-19 pandemic has reinforced the importance of critical care pharmacists in assuming responsibility for managing medication therapy in direct patient care settings. Historically, pharmacists have been relied upon for prospective evaluation of drug therapy for appropriate indications, dosage, drug interactions, and drug allergies; monitoring patients' pharmacotherapeutic regimens for effectiveness and adverse effects; providing drug information to providers; and educating health professionals regarding drug therapies. Specific to COVID-19, pharmacists have been an integral member of the multidisciplinary rounding team, assisting with drug shortages and strategies for drug conservation; participating in emergencies, such as advanced cardiac life support (ACLS) and rapid sequence intubations; and creating as well as integrating evidence-based guidelines and pathways during the pandemic into clinical practice. The purpose of this article is to demonstrate the various roles of critical care pharmacists among the healthcare team in caring for critically ill COVID-19 patients.

A comparison of insulin doses for treatment of hyperkalaemia in intensive care unit patients with renal insufficiency.

BACKGROUND: Hyperkalaemia is a complication in patients with chronic kidney disease or acute kidney injury and occurs frequently in the intensive care unit. One treatment approach includes intravenous (IV) insulin to shift potassium intracellularly. OBJECTIVES: The primary outcome was hypoglycaemia (blood glucose <70 mg/dL) after insulin administration. Secondary outcomes included change in serum potassium levels and incidence of severe hypoglycaemia. METHODS: This was a single-centre, retrospective study evaluating critically ill adult patients with chronic kidney disease stage III-V, end-stage renal disease, or acute kidney injury who received IV insulin for treatment of hyperkalaemia from March 2008 to September 2018. Patients were divided into two insulin-dosing regimen groups: 5 units or 10 units. RESULTS: Of the 174 patients included, hypoglycaemia after insulin administration occurred in eight of 87 patients (9.2%) in the 5-unit group and 17 of 87 patients (19.5%) in the 10-unit group (p = 0.052). There was no difference in rates of severe hypoglycaemia or change in serum potassium levels. CONCLUSIONS: In critically ill patients requiring treatment for hyperkalaemia, a lower dose of IV insulin does not result in lower statistically significant rates of hypoglycaemia. However, lower insulin doses provide a similar potassium-lowering effect and cause a meaningful decrease in hypoglycaemic episodes. Intensive care unit providers may consider 5 units of IV insulin over 10 units although further larger controlled studies are needed.

The impact of antihypertensive use in the treatment of acute ischemic stroke in patients receiving alteplase.

BACKGROUND: Treatment of acute ischemic stroke (AIS) with intravenous alteplase within 4.5 h of symptom onset is associated with neurologic improvement. High baseline blood pressure (BP) and BP variability during the first 24 h of AIS is associated with increased early adverse events and death. The purpose of this study is to characterize the incidence of poor neurologic outcome in patients treated with alteplase for AIS who received antihypertensive medications prior to and within the first 24 h following alteplase administration compared with patients who did not. METHODS: This was a multicenter, retrospective cohort of patients >18 years diagnosed with AIS from January 1, 2011 through December 31, 2015 who received one or more antihypertensive medication in the first 24 h of AIS in patients receiving alteplase compared to controls. The primary endpoint was poor neurologic outcome at 90 days, according to modified Rankin Scale ≥3. Univariate analysis was conducted using Chi-square, Fisher's exact test, or Mann-Whitney U test. Multivariable logistic regression was conducted to determine independent predictors of poor outcome. RESULTS: Of the 587 patients evaluated, 351 (59.7%) were included, of which 127 (36.2%) received antihypertensive(s). More patients in the antihypertensive treatment group had a history of hypertension (88.2% vs. 69.6%, p < 0.01), diabetes (37% vs. 25.5%, p = 0.03) and chronic kidney disease (19.7% vs. 8.5%, p < 0.01). Intravenous push labetalol was most commonly administered (81.2%), followed by nicardipine (44.1%), and hydralazine (22%). More patients in the antihypertensive treatment group experienced poor neurologic outcome at 90 days (53.5% vs. 38.8%, p < 0.01), however, this finding was not observed after multivariable logistic regression. CONCLUSION: Antihypertensive treatment in the first 24 h of AIS was associated with poor neurologic outcomes at 90 days. However, after controlling for other clinical factors in a multivariable logistic regression, this association was no longer observed.

Urinary tract infection pocket card effect on preferred antimicrobial prescribing for cystitis among patients discharged from the emergency department.

PURPOSE: To evaluate the impact of a urinary tract infection (UTI) pocket card on preferred antibiotic prescribing for patients discharged from the emergency department (ED) with a diagnosis of cystitis. METHODS: A multicenter, retrospective, pre-post study was conducted to compare outcomes following the introduction of a UTI pocket card. The primary outcome was prescribing rates for institutional first-line preferred antibiotics (cephalexin and nitrofurantoin) versus other antimicrobials for cystitis. Secondary outcomes included prescriber adherence to recommended therapy in regards to discharge dose, frequency, duration, and healthcare utilization rates. RESULTS: The study included 915 patients in total, 407 in the preintervention group and 508 in the postintervention group. The frequency of preferred antibiotic prescribing was significantly increased after the introduction of a UTI pocket card compared to prior to its introduction (81.7% vs 72.0%, P = 0.001). Significant increases in prescribing of an appropriate antibiotic dose (78.0% vs 66.8%, P < 0.0001) and frequency (64.2% vs 47.4%, P < 0.0001) were also found post intervention. No significant differences were seen between the pre- and postintervention groups with regards to healthcare utilization rates. CONCLUSION: A UTI pocket card increased preferred antibiotic prescribing for cystitis in the ED. This study provides data on a successful antimicrobial stewardship intervention in the ED setting.

Emergency department methicillin-resistant Staphylococcus aureus nare screen effect on pneumonia treatment duration.

STUDY OBJECTIVE: The objective of this study was to determine if performing a methicillin-resistant Staphylococcus aureus (MRSA) nasal screen in the emergency department (ED) decreased general medicine patient exposure to anti-MRSA antibiotics for pneumonia. METHODS: This was a single-center, retrospective study evaluating patients who had a diagnosis of pneumonia and were initiated on anti-MRSA therapy (vancomycin or linezolid) in the ED and subsequently admitted to a general medicine floor. Patients were divided into two groups: 1) did not receive a MRSA nares screen in the ED (No MRSA screen group) or 2) received a MRSA nares screen in the ED (MRSA screen group). The primary outcome was anti-MRSA antibiotic duration. Secondary outcomes included vancomycin level evaluation, hospital survival, and acute kidney injury. RESULTS: Of the 116 patients included, 37 patients received a MRSA nares screen in the ED and 79 patients did not. Median duration of antibiotic exposure was similar for both groups (No MRSA screen, 30.5 h [interquartile range (IQR) 20.5-52.5] vs. MRSA screen, 24.5 h [IQR 20.6-40.3]; p = 0.28). Of patients who were screened, 35 were negative and 2 were positive. Secondary outcomes were similar. CONCLUSION: Performing a MRSA nares screen in the ED for patients diagnosed with pneumonia, initiated on anti-MRSA antibiotics, and admitted to a general medicine floor did not decrease duration of anti-MRSA antibiotics. At this time, ED providers do not need to consider a MRSA nasal screen in the ED for patients being admitted to general medicine, although larger studies could be considered.