2011 August 20

Transcutaneous pressure at which the internal jugular vein is collapsed on ultrasonic imaging predicts easiness of the venous puncture.

Aug 202011

Transcutaneous pressure at which the internal jugular vein is collapsed on ultrasonic imaging predicts easiness of the venous puncture.

J Anesth. 2011 Apr;25(2):308-11

Authors: Joo WJ, Fukui M, Kooguchi K, Sakaguchi M, Shinzato T

Abstract
Even though we use ultrasound guidance for central venous puncture, we sometimes experience difficulties. We infer that in such cases the vein is collapsed and that the transcutaneous ultrasound probe pressure at which the vein is collapsed (P (tc)) may predict the easiness of the venous puncture. We measured P (tc) and the diameter of the internal jugular vein in 47 adult patients in our ICU. After successful puncture, we also measured venous pressure (P (v)). The patients were divided into two groups based on the number of puncture attempts: ?3 attempts constituted the "difficult group" and <3 attempts was considered the "easy group:" 33 patients were in the easy group and 14 patients were in the difficult group. The easy group showed significantly higher P (tc) value (9.3 ± 3.8 vs. 3.5 ± 0.9 cmH(2)O, P < 0.0001) and larger vertical diameter (9.2 ± 3.1 vs. 6.8 ± 2.2 mm, P = 0.013) than the difficult group. We observed a clear border between the minimum P (tc) in the easy group (6 cmH(2)O) and the maximum value in the difficult group (5 cmH(2)O). In conclusion, venous collapsibility and vertical diameter determine difficulty in performing venous puncture.

PMID: 21229272 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis.

Europace Start a Discussion »

Aug 202011

Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis.

Europace. 2011 May;13(5):723-46

Authors: Lip GY, Andreotti F, Fauchier L, Huber K, Hylek E, Knight E, Lane DA, Levi M, Marin F, Palareti G, Kirchhof P, , Collet JP, Rubboli A, Poli D, Camm J

Abstract
Despite the clear net clinical benefit of oral anticoagulation (OAC) in atrial fibrillation (AF) patients at risk for stroke, major bleeding events (especially intra-cranial bleeds) may be devastating events when they do occur. The decision for OAC is often based on a careful assessment of both stroke risk and bleeding risk, but clinical scores for bleeding risk estimation are much less well validated than stroke risk scales. Also, the estimation of bleeding risk is rendered difficult since many of the known factors that increase bleeding risk overlap with stroke risk factors. As well as this, many factors that increase bleeding risk are transient, such as variable international normalized ratio values, operations, vascular procedures, or drug-drug and food-drug interactions. In this Position Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in AF patients, with a view to summarizing 'best practice' when approaching antithrombotic therapy in AF patients. We address the epidemiology and size of the problem of bleeding risk in AF and review established bleeding risk factors. We also summarize definitions of bleeding in the published literature. Patient values and preferences balancing the risk of bleeding against thrombo-embolism is reviewed, and the prognostic implications of bleeding are discussed. We also review bleeding risk stratification and currently published bleeding risk schema. A brief discussion of special situations [e.g. peri-ablation, peri-devices (implantable cardioverter-defibrillator, pacemakers) and presentation with acute coronary syndromes and/or requiring percutaneous coronary interventions/stents and bridging therapy], as well as a discussion of prevention of bleeds and managing bleeding complications, is made. Finally, this document also puts forwards consensus statements that may help to define evidence gaps and assist in everyday clinical practice. Bleeding risk is almost inevitably lower than stroke risk in patients with atrial fibrillation. Nonetheless, identification of patients at high risk of bleeding and delineation of conditions and situations associated with bleeding risk can help to refine antithrombotic therapy to minimize bleeding risk.

PMID: 21515596 [PubMed - indexed for MEDLINE]

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Deep vein thrombosis and pulmonary embolism in hospitalized patients with cirrhosis: a nationwide analysis.

Dig Dis Sci Start a Discussion »

Aug 202011

Deep vein thrombosis and pulmonary embolism in hospitalized patients with cirrhosis: a nationwide analysis.

Dig Dis Sci. 2011 Jul;56(7):2152-9

Authors: Ali M, Ananthakrishnan AN, McGinley EL, Saeian K

Abstract
BACKGROUND AND AIMS: Recent studies have shown conflicting results regarding the risk of venous thromboembolism (VTE) in cirrhotics despite the often-associated coagulopathy. Our aim was to determine burden and risk factors for VTE in cirrhotics from a national sample.
METHODS: Using data from the Nationwide Inpatient Sample 2005, we identified cirrhosis-related hospitalizations using appropriate discharge codes. Our outcomes of interest were deep venous thrombosis (DVT) or pulmonary embolism (PE). Cirrhotics without VTE formed the controls. Multivariate regression models were used to identify factors independently associated with VTE and the impact of VTE diagnosis on in-hospital outcomes.
RESULTS: There were 449,798 hospitalizations for cirrhosis in 2005 of which 8,231 were for VTE (1.8%). This rate was lower than the rate for chronic hepatitis C (2.4%) or all-cause hospitalizations (3.7%). Patients with VTE were older than controls and had greater co-morbidity and were more likely to have malnutrition, parenteral nutrition, prolonged mechanical ventilation, and central venous line (CVL) placement. Complications of cirrhosis including hepatic encephalopathy, variceal bleeding, ascites, and coagulopathy were less frequent in those with VTE than controls. On multivariate regression, greater co-morbidity, black race, malnutrition, and CVL placement were independently associated with VTE. Neither DVT nor PE was associated with greater in-hospital mortality. DVT, but not PE, was associated with a 52% increase in LOS and hospitalization charges.
CONCLUSIONS: Despite the often-associated coagulopathy, VTE contributes to a significant burden in patients with cirrhosis. Efforts directed at VTE prevention in this cohort, especially high-risk patients, should be actively pursued.

PMID: 21279685 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Integrated post-discharge transitional care in a hospitalist system to improve discharge outcome: An experimental study.

BMC Med Start a Discussion »

Aug 202011

Integrated post-discharge transitional care in a hospitalist system to improve discharge outcome: An experimental study.

BMC Med. 2011 Aug 17;9(1):96

Authors: Shu CC, Hsu NC, Lin YF, Wang JY, Lin JW, Ko WJ

Abstract
ABSTRACT: BACKGROUND: The post-discharge period is a vulnerable time for patients with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because post-discharge care continuity is easily interrupted after hospitalist care, close follow-up may decrease readmission. This study aimed to investigate the impact of a quality improvement program - integrated post-discharge transitional care (PDTC) - in Taiwan's hospitalist system. METHODS: From December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan, and discharged alive to home care were included. Quality improvement intervention in the PDTC program, including disease-specific care plan, telephone monitoring, hotline counseling, and referral to hospitalist-run clinic were performed in the latter four months in the intervention group while the control group was recruited in the first two months of the study period. The primary endpoint was unplanned readmission or death within 30 days after discharge. RESULTS: There were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics on admission and discharge. In the intervention group, 18 patients with worsening disease-specific indicators by telephone monitoring and 21 with new/worsening symptoms by hotline counseling were associated with a higher rate of unplanned readmission than those without worsening indicator (p=0.031) and symptoms (p=0.019), respectively. Those who received PDTC had lower rate of readmission and death within 30 days post-discharge than the control group (15% vs. 25%, p=0.021). Non-use of a hospitalist-run clinic and presence of underlying malignancy were other independent factors for 30-day post-discharge readmission and death. CONCLUSION: Integrated PDTC using disease-specific care, telephone monitoring, hotline counseling, and a hospitalist-run clinic can reduce post-discharge readmission and death.

PMID: 21849018 [PubMed - as supplied by publisher]

Link to Article at PubMed

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

J Am Med Inform Assoc Start a Discussion »

Aug 202011

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

J Am Med Inform Assoc. 2011 Aug 17;

Authors: McCoy AB, Waitman LR, Lewis JB, Wright JA, Choma DP, Miller RA, Peterson JF

Abstract
Objective Alerting systems, a type of clinical decision support, are increasingly prevalent in healthcare, yet few studies have concurrently measured the appropriateness of alerts with provider responses to alerts. Recent reports of suboptimal alert system design and implementation highlight the need for better evaluation to inform future designs. The authors present a comprehensive framework for evaluating the clinical appropriateness of synchronous, interruptive medication safety alerts. Methods Through literature review and iterative testing, metrics were developed that describe successes, justifiable overrides, provider non-adherence, and unintended adverse consequences of clinical decision support alerts. The framework was validated by applying it to a medication alerting system for patients with acute kidney injury (AKI). Results Through expert review, the framework assesses each alert episode for appropriateness of the alert display and the necessity and urgency of a clinical response. Primary outcomes of the framework include the false positive alert rate, alert override rate, provider non-adherence rate, and rate of provider response appropriateness. Application of the framework to evaluate an existing AKI medication alerting system provided a more complete understanding of the process outcomes measured in the AKI medication alerting system. The authors confirmed that previous alerts and provider responses were most often appropriate. Conclusion The new evaluation model offers a potentially effective method for assessing the clinical appropriateness of synchronous interruptive medication alerts prior to evaluating patient outcomes in a comparative trial. More work can determine the generalizability of the framework for use in other settings and other alert types.

PMID: 21849334 [PubMed - as supplied by publisher]

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Variability of INR and its relationship with mortality, stroke, bleeding and hospitalisations in patients with atrial fibrillation.

Thromb Res Start a Discussion »

Aug 202011

Variability of INR and its relationship with mortality, stroke, bleeding and hospitalisations in patients with atrial fibrillation.

Thromb Res. 2011 Aug 16;

Authors: Lind M, Fahlén M, Kosiborod M, Eliasson B, Odén A

Abstract
BACKGROUND - RATIONALE FOR STUDY: Atrial fibrillation is associated with an increased risk of stroke and mortality which is reduced by treatment with Warfarin. The most commonly used tool to assess the effectiveness of warfarin therapy is the time in therapeutic Range (TTR) of International Normalised Ratio (INR) 2.0-3.0. Our aim was to study whether INR variability, as assessed by the standard deviation of transformed INR (SDT(INR)) is more prognostically important than the TTR. METHODS AND RESULTS: We studied 19,180 patients with atrial fibrillation on warfarin therapy to evaluate the association of TTR and that of SDT(INR) with all-cause mortality, stroke, bleeding and hospitalisation. The SDT(INR) was more prognostically important than the TTR. One standard deviation (SD) higher of SDT(INR) had a hazard ratio (HR) of 1.59 (95% CI 1.52-1.66) of mortality compared with 1.18 (95% CI 1.13-1.24) for one SD lower of TTR. For the other 3 events the HR was also higher for the SDT(INR) than for the TTR (stroke 1.30 (95% CI 1.22-1.39) vs. 1.06 (95% CI 1.00-1.13), bleeding 1.27 (95% CI 1.20-1.35) vs. 1.07 (95% CI 1.01-1.14) , hospitalisation 1.47 (95% CI 1.45-1.49) vs. 1.13 (95% CI 1.10-1.15). When both metrics were included in the same analysis only the SDT(INR) was of significant predictive value. CONCLUSIONS: The SDT(INR) is a better predictor of mortality, stroke, bleeding and hospitalisation than the TTR in patients with atrial fibrillation receiving warfarin therapy.

PMID: 21851969 [PubMed - as supplied by publisher]

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