ED Resident Conferences: Wednesday, April 23, 2014

Teaching Attending: Lauren Conlon, MD

All conferences will be held in the John Pryor Conference Room on Ground Founders

8:00 am – 8:50 am: Diagnostics Conference: AJ Dean, MD and Nova Panebianco, MD
9:00 am – 10:00 am: Grand Rounds: “Emergency Management of Inherited Bleeding Disorders” Patrick F Fogarty, MD
10:00 am – 10:15 am Resident Updates: Program leadership (Francis, Lauren and Mira)
10:15 am – 11:00 am EPIC: Chris Edwards, MD and Chris Boedec
11:10 am – 12:00 pm Case Discussion
12:00 pm – 1:00 pm Joint EM/IM Conference (5th Floor Maloney)

Resident Conference: Wednesday, April 16th, 2014

Teaching Attending: Mira Mamtani, MD
All conferences will be held in the John Pryor Conference Room on Ground Founders

8:00 am – 8:50 am Chief Conference: Andrew Baum, MD
9:00 am – 10:00 am Grand Rounds: “Extracorporeal Life Support in the ED: Where are we? And where are we going?” Nick Johnson, MD
10:00 am – 11:00 am Clinical Case Conference: Dave Grasso, MD
11:00 am – 12:00 pm Jeopardy: Tom Grosheider, MD

Evidence in the ED: LMNOP in ADHF: Should Lasix Stay in the Acronym? by Amos Shemesh

Take home: Loop diuretics are a Level C recommendation in ADHF and are appropriate to use, though high doses early in management of acute cardiogenic pulmonary edema may be harmful or lead to further complications.

?… and maybe consider holding off on diuretics in patients with ADHF and worsening renal function

Evidence in the ED: FAST Exam in Pediatric Trauma by Sarah Cavallaro

Take home: If positive, a FAST exam may still be helpful to locate the source of bleeding in blunt traumatic pediatric patients presenting with hemorrhagic shock. It is not however a study that can replace CT scan for diagnosis of all intra-abdominal injury in hemodynamically stable pediatric patients.

Evidence FAST Exam Peds Cavallaro

(Still, not so) Normal Saline by Nick Johnson

There’s been a fair amount of excellent discussion among residents, nurses, and faculty lately in the ED about the potential downsides of large-volume resuscitation of critically ill patients with isotonic saline. In light of this, I wanted to share a study that was just published in Critical Care Medicine, along with a bit of context.
For many years, it has been known that resuscitation with unbalanced solutions such as isotonic saline (meaning fluids that have a strong ion difference of zero and have a pH much lower than plasma) causes metabolic derangement; isotonic saline causes a hyperchloremic metabolic acidosis. While this has troubled (especially surgical) intensivists for some time, untoward patient-centered effects had not definitively been demonstrated until recently. Over the past five years, a number of studies have been published demonstrating increased morbidity and renal dysfunction among critically ill patients treated  with isotonic saline as compared with balanced solutions (i.e. Lactated Ringer’s or PlasmaLyte). The most notable of these studies found a decreased incidence of AKI and renal replacement therapy among ICU patients in Australia treated with a chloride-restrictive (i.e. less isotonic saline) fluid strategy.
Enter the current study. This group retrospectively looked at over 50,000 patients with ICD-code identified sepsis who were admitted to the ICU and on vasopressors. Becauseonly a small subset of these patients were treated with balanced fluids (and this subset differed substantially from the larger group – in some ways, sicker; in other ways, less ill), they performed a propensity analysis comparing the 3300 patients treated with balanced fluids with 3300 matched patients treated with isotonic saline. In this analysis, they found lower overall mortality (19 vs 22%) among the patients treated with balanced solution (in this study, predominantly LR). In addition, they observed progressively lower mortality among patients who received a greater proportion of balanced fluid, suggesting a dose response. Interestingly, there were no differences in AKI. Clearly, this study has some limitations given it’s retrospective nature, use of ICD codes to define cases of sepsis, and differences between groups (mitigated somewhat by the propensity analysis).
Nonetheless, given the mounting data, we should all consider the importance of choosing the right fluid for the right patient, like we would for any other medication. It’s also important to note that LR costs approximately twice as much as NS per bag ($2 vs $4, according to one study), but the same group that published the above 2012 JAMA study found that restricting isotonic saline actually led to decreased overall fluid cost among ICU patients.

For me, I’ll continue to use saline in young, healthy patients that I’m treating for dehydration related to conditions like gastroenteritis, pyleonephritis, hyperemesis, migraine, etc. In critically ill patients headed to the ICU and expected to receive greater than 2-3 liters, switching to LR (unless a specific contraindication such as hyperkalemia exists) makes the most sense.

For the nerdy few who are interested in this, John Myburgh wrote a nice review of resuscitation fluids in the NEJM in late 2013 that’s worth a read.

Some other great resources on this topic:
EMCrit on chloride poisoning
PulmCCM Central covers normal saline and renal failure
EMCrit’s mind-blowing 4-part acid-base review

- Nick Johnson, EM Chief Resident