The effect of alpha-blockade in emergency department patients with ureterolithiasis.

BACKGROUND: Recent studies suggest that alpha-blockade with tamsulosin may be useful in the treatment of ureterolithiasis by increasing the success of, and decreasing the time to, stone passage. OBJECTIVES: We sought to determine stone passage success rates in patients diagnosed with ureterolithiasis and discharged from our Emergency Department (ED) with tamsulosin. METHODS: We conducted a non-randomized retrospective cohort study over a 1-year period during which we made monthly follow-up telephone calls to patients discharged from our ED with a diagnosis of ureterolithiasis determined by computed tomography (CT) scan. Stone size and location (proximal, middle, or distal ureter) were determined from radiologist reports and prescriptions were determined from electronic medical records. Patients were asked if they spontaneously passed their stone, how much time was required before stone passage, and if any subsequent hospital visit was required after discharge due to pain or complication resulting from the ureteral stone. RESULTS: During the study, a total of 213 patients were discharged from the ED with ureterolithiasis diagnosed by CT scan; of these, 119 (56%) were successfully contacted and 113 (53%) agreed to participate. Of the 113 patients, 83 (73%) had been prescribed tamsulosin and 30 (27%) had not. Overall age (43 years), gender (67% male), median stone size (3 mm, interquartile range 2-4 mm), and location (71% distal ureter) were similar in the two cohorts. Of tamsulosin recipients, 84% (95% confidence interval [CI] 75-91%) reported passing their stone, whereas 60% (95% CI 42-75%) of non-recipients passed their stone. CONCLUSION: Patients with ureterolithiasis discharged from our ED and given tamsulosin by prescription had moderately high ureteral stone passage success rates in our non-randomized retrospective cohort study. Compared to non-recipients of tamsulosin, patients receiving tamsulosin seemed to have greater success in stone passage.

Emergency physicians report infrequent use of alpha-blockade for the treatment of ureteral stones.

PURPOSES: We sought to determine how frequently tamsulosin is used by emergency physicians (EPs) for the treatment of patients with ureteral stones, and examine factors influencing its use. BASIC PROCEDURES: We distributed online and paper surveys to 240 EPs in five states in the United States. Surveys asked the length of time in practice, the type of hospital setting, and the self-reported frequency of tamsulosin use by quartile. FINDINGS: A total of 103 EPs (43%) responded to the survey. The majority (60%, 95% CI 51% to 69%) reported the use of tamsulosin in fewer than 25% of patients presenting with ureteral stones, and many (27%, 95% CI 20% to 36%) had not heard of the use of tamsulosin for urinary-stone passage. Practice in a county hospital was associated with infrequent tamsulosin use (p=.02). CONCLUSIONS: Despite evidence that alpha-blockade may be beneficial to patients presenting to the emergency department with ureteral stones, this approach is still used inconsistently by EPs.

The effect of single-bolus etomidate on septic patient mortality: a retrospective review.

BACKGROUND: Because of its many desirable properties, etomidate is widely used as an induction agent for endotracheal intubation. However, some have recently called into question the safety of etomidate for even single-bolus use due to its known effects on adrenal suppression. OBJECTIVES: We sought to compare the in-hospital mortality between septic patients given etomidate and those given alternative induction agents for intubation. METHODS: We performed a retrospective chart review of intubated septic patients treated in our hospital. We collected data from patients over the age of 18 with sepsis who were intubated in the pre-hospital setting, in our emergency department, or on the wards of our hospital, and calculated the in-hospital mortality of each group. RESULTS: We identified 181 patients with sepsis who were intubated over the study period; 135 received etomidate and 46 received alternative agents or no induction agent. Baseline characteristics, vital signs, and laboratory values were similar between the two groups. Of the 46 patients receiving alternative agents or no agent, 18 died, yielding an unadjusted mortality of 39.1% (95% CI 25.5% to 54.6%), while of the 135 patients receiving etomidate, 63 died, for an unadjusted mortality of 46.7% (95% CI 38.1% to 55.4%), P=0.38. CONCLUSION: We found a non-statistically significant 7.6% absolute increase in mortality in patients given etomidate in our small-sized study population.