Push-Dose Vasopressin for Hypotension in Septic Shock.

BACKGROUND: Peri-intubation cardiac arrest and hypotension in patients with septic shock occur often in the emergency department (ED) and ultimately lead to worse clinical outcomes. In recent years, the use of push-dose, or bolus-dose, vasopressors in the ED have become common practice for transient hypotension and bridging to continuous infusion vasopressors. Push-dose epinephrine and phenylephrine are the agents used most frequently in this scenario. CASE REPORT: A 63-year-old woman who was apneic and pulseless presented to our ED. After 4 min of cardiopulmonary resuscitation, spontaneous circulation was achieved, and the patient was intubated for airway protection. She became hypotensive with a blood pressure of 55/36 mm Hg. After receiving a 1-L bolus of lactated Ringer solution, she remained hypotensive with blood pressure of 80/51 mm Hg and a pulse of 129 beats/min. One unit of intravenous vasopressin push bolus was administered. Within 1 min, her hemodynamics improved to a blood pressure of 141/102 mm Hg and pulse of 120 beats/min. Over the next 2 h, her mean arterial pressure slowly and progressively declined from 120 to 80. No further vasoactive medications were required for approximately 120 min until norepinephrine and vasopressin was initiated for septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report discusses the use of push-dose vasopressin as an alternate vasoactive medication to improve hemodynamics in a patient with vasodilatory septic shock.

Aggressive Versus Conservative Initial Diuretic Dosing in the Emergency Department for Acute Decompensated Heart Failure.

BACKGROUND: Intravenous (IV) loop diuretics are recommended to relieve vascular congestion in patients with acute decompensated heart failure (ADHF); however, initial dosing is often empirical. Strong evidence supporting individualized diuretic dosing in the emergency department (ED) is lacking. OBJECTIVE: The purpose of this study was to compare the efficacy and safety of aggressive (≥2 daily home doses) and conservative (<2 daily home doses) initial doses of loop diuretic. METHODS: This was a retrospective cohort study in adult patients presenting to the ED with ADHF at an academic medical center from Apri 2015 to September 2015. The primary outcome was time to transition from IV to oral diuretics. RESULTS: A total of 91 patients were included (aggressive dosing, n = 44; conservative dosing, n = 47). Mean time to transition from IV to oral diuretics was 67.9 hours in the aggressive group compared with 88.1 hours in the conservative group ( P = 0.049). Mean hospital length of stay (LOS) was 119.5 hours in the aggressive group versus 123.0 hours in the conservative group ( P = 0.799). No differences were observed between the mean urine output ( P = 0.829), change in body weight ( P = 0.528), or serum creatinine ( P = 0.135). CONCLUSION: Patients who received an aggressive initial diuretic dose in the ED had a significantly faster time to oral diuretic therapy without any significant differences in hospital LOS, urine output, change in body weight, and renal function when compared with conservative dosing.

Comparative effectiveness of 3- versus 4-factor prothrombin complex concentrate for emergent warfarin reversal.

INTRODUCTION: Three- and 4-factor prothrombin complex concentrates (PCC) are routinely administered for emergent reversal of warfarin, but direct comparisons of clinical outcomes are lacking. The purpose of this study was to compare the safety and effectiveness of 3- and 4-PCC in patients requiring emergent warfarin reversal. MATERIALS AND METHODS: This was a single-center retrospective study in adult patients requiring administration of either 3-PCC or 4-PCC for emergent reversal of warfarin. RESULTS: One hundred sixty-five patients were included (3-PCC, n=109; 4-PCC, n=56). The most frequent indications for PCC were intracranial and gastrointestinal bleeding. Baseline median INR was 2.5 (2.0-3.2) and 2.4 (2.0-4.2) in the 3-PCC and 4-PCC groups. Thirty minutes after PCC administration, median INR decreased to 1.3 in both groups (p<0.001), and 87 (80%) versus 47 (84%) of patients had INR values≤1.5 (p=0.52) in the 3-PCC group versus the 4-PCC group. Thromboembolic events occurred in 7 patients (4%) and were similar between the 3-PCC (n=3, 3%) and 4-PCC (n=4, 7%) groups (p=0.23). Thirty-four (31%) patients in the 3-PCC group died compared to 5 patients (9%) in the 4-PCC group (p=0.001). INR>1.5 thirty minutes after PCC was associated with increased mortality (OR 4.3; 95% CI 1.8-10.4, p=0.001), and administration of a 4-PCC was associated with decreased mortality (OR 0.19; 95% CI 0.06-0.54, p=0.002). CONCLUSION: Patients who received 4-PCC, and those with INR≤1.5 regardless of type of PCC received were more likely to survive. Thromboembolic events were low in both groups and similar to previous studies.

Lack of association of the HMGA1 IVS5-13insC variant with type 2 diabetes in an ethnically diverse hypertensive case control cohort.

BACKGROUND: Recently, the high-mobility group A1 gene (HMGA1) variant IVS5-13insC has been associated with type 2 diabetes, but reported associations are inconsistent and data are lacking in Hispanic and African American populations. We sought to investigate the HMGA1-diabetes association and to characterize IVS5-13insC allele frequencies and linkage disequilibrium (LD) in 3,070 Caucasian, Hispanic, and African American patients from the INternational VErapamil SR-Trandolapril STudy (INVEST). METHODS: INVEST was a randomized, multicenter trial comparing two antihypertensive treatment strategies in an ethnically diverse cohort of hypertensive, coronary artery disease patients. Controls, who were diabetes-free throughout the study, and type 2 diabetes cases, either prevalent or incident, were genotyped for IVS5-13insC using Taqman®, confirmed with Pyrosequencing and Sanger sequencing. For LD analysis, genotyping for eight additional HMGA1 single nucleotide polymorphisms (SNPs) was performed using the Illumina® HumanCVD BeadChip. We used logistic regression to test association of the HMGA1 IVS5-13insC and diabetes, adjusted for age, gender, body mass index, and percentage European, African, and Native American ancestry. RESULTS: We observed IVS5-13insC minor allele frequencies consistent with previous literature in Caucasians and African Americans (0.03 in cases and 0.04 in controls for both race/ethnic groups), and higher frequencies in Hispanics (0.07 in cases and 0.07 in controls). The IVS5-13insC was not associated with type 2 diabetes overall (odds ratio 0.98 [0.76-1.26], p=0.88) or in any race/ethnic group. Pairwise LD (r2) of IVS5-13insC and rs9394200, a SNP previously used as a tag SNP for IVS5-13insC, was low (r2=0.47 in Caucasians, r2=0.25 in Hispanics, and r2=0.06 in African Americans). Furthermore, in silico analysis suggested a lack of functional consequences for the IVS5-13insC variant. CONCLUSIONS: Our results suggest that IVS5-13insC is not a functional variant and not associated with type 2 diabetes in an ethnically diverse, hypertensive, coronary artery disease population. Larger, more adequately powered studies need to be performed to confirm our findings.