2011 November 01

Optimized method for correct left-sided central venous catheter placement under electrocardiographic guidance.

Nov 012011

Optimized method for correct left-sided central venous catheter placement under electrocardiographic guidance.

Br J Anaesth. 2011 Oct;107(4):567-72

Authors: Kremser J, Kleemann F, Reinhart K, Schummer W

Abstract
BACKGROUND: Central venous catheter (CVC) placement under ECG guidance in the left thoracocervical area can lead to catheter misplacement. The aim of this study was to identify the cause and quantify the magnitude of this error.
METHODS: CVCs were sited in either the left or right internal jugular (IJ), subclavian (SC), or innominate (brachiocephalic) vein using the Seldinger technique and a total of 227 insertions were studied. The position of the catheter tip was confirmed with two different intra-atrial ECG monitoring methods (Seldinger's wire vs 10% saline solution). Measurements were compared between the two methods and correlated to the different access sites.
RESULTS: All right-sided CVC had the line tip in the optimal position and both intra-atrial ECG recording by Seldinger's wire or 10% saline delivered correct results. For left-sided lines, however, the two methods gave significantly different results regarding the position of the line tip for each insertion site. When using the Seldinger wire as intravascular ECG lead, the results differed from the saline method by a mean of 21 mm for the IJ and 10 mm for the SC.
CONCLUSIONS: CVC placement under ECG guidance is a reliable method to site the line tip at the optimal position. However, when using a left-sided thoracocervical access point, the Seldinger wire-conducted ECG delivered a constant error. This could be adjusted for by advancing the CVC 20 mm in addition to the wire-based measurement of the insertion depth at the left IJ vein and 10 mm at the left SC vein.

PMID: 21697183 [PubMed - indexed for MEDLINE]

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Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia.

J Hosp Med Start a Discussion »

Nov 012011

Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia.

J Hosp Med. 2011 Oct 28;

Authors: Madaras-Kelly KJ, Remington RE, Fan VS, Sloan KL

Abstract
OBJECTIVE: To develop and validate a model to predict resistance to community-acquired pneumonia antibiotics (CAP-resistance) among patients with healthcare-associated pneumonia (HCAP), and to compare the model's predictive performance to a model including only guideline-defined criteria for HCAP. DESIGN: Retrospective cohort study. SETTING: Six Veterans Affairs Medical Centers in the northwestern United States. PATIENTS: Culture-positive inpatients with HCAP. MEASUREMENTS: Patients were identified based upon guideline-defined criteria for HCAP. Relevant cultures obtained within 48 hours of admission were assessed to determine bacteriology and antibiotic susceptibility. Medical records for the year preceding admission were assessed to develop predictive models of CAP-resistance with logistic regression. The predictive performance of cohort-developed and guideline-defined models was compared. RESULTS: CAP-resistant organisms were identified in 118 of 375 culture-positive patients. Of guideline-defined criteria, CAP-resistance was associated (odds ratio (OR) [95% confidence interval (CI)]) with: admission from nursing home (2.6 [1.6-4.4]); recent antibiotic exposure (1.7 [1.0-2.8]); and prior hospitalization (1.6 [1.0-2.6]). In the cohort-developed model, CAP-resistance was associated with: admission from nursing home or recent nursing home discharge (2.3 [1.4-3.8]); positive methicillin-resistant Staphylococcus aureus (MRSA) history within 90 days of admission (6.4 [2.6-17.8]) or 91-365 days (2.3 [0.9-5.9]); cephalosporin exposure (1.8 [1.1-2.9]); recent infusion therapy (1.9 [1.0-3.5]); diabetes (1.7 [1.0-2.8]); and intensive care unit (ICU) admission (1.6 [1.0-2.6]). Area under the receiver operating characteristic curve (aROC [95% CI]) for the cohort-developed model (0.71 [0.65-0.77]) was significantly higher than for the guideline-defined model (0.63 [0.57-0.69]) (P = 0.01). CONCLUSIONS: Select guideline-defined criteria predicted CAP-resistance. A cohort-developed model based primarily on prior MRSA history, nursing home residence, and specific antibiotic exposures provided improved prediction of CAP-resistant organisms in HCAP. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

PMID: 22038859 [PubMed - as supplied by publisher]

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Pocket card and dedicated feedback session to improve feedback to ward residents: A randomized trial.

J Hosp Med Start a Discussion »

Nov 012011

Pocket card and dedicated feedback session to improve feedback to ward residents: A randomized trial.

J Hosp Med. 2011 Oct 28;

Authors: Peccoralo L, Karani R, Coplit L, Korenstein D

Abstract
BACKGROUND: Residents are often dissatisfied with feedback received on the wards, and hospital attendings are often uncomfortable and unskilled at giving feedback. OBJECTIVE: Determine the impact of a pocket card and feedback session on Internal Medicine (IM) residents' perceptions of feedback and attendings' comfort giving feedback. DESIGN: Prospective randomized trial using chi-square analysis. SETTING: Inpatient wards at 1 academic medical center. PARTICIPANTS: One hundred eleven IM residents and 36 attendings. INTERVENTION: We introduced a pocket feedback card, structured around the Accreditation Council for Graduate Medical Education competencies, and a feedback session to guide mid-rotation feedback. Control group attendings received the usual reminder to provide feedback. MEASUREMENTS: Attendings' and residents' survey responses, after the inpatient month, assessing attitudes towards feedback and qualitative interviews with intervention attendings. RESULTS: Intervention residents were more likely than controls to report sufficient and useful feedback from attendings. They reported more feedback regarding skills needing improvement and how to improve their skills (51.3% vs 25.5%, P = 0.02), and felt their clinical (61.5% vs 27.8%, P = 0.001) and professionalism/communication (51.3% vs 29.1%, P = 0.03) skills improved based on this feedback. Intervention attendings, as compared to controls, agreed that residents improved their professionalism/communication skills (76.9% vs 31.1%, P = 0.02) based on feedback. Most intervention attendings found the card and session acceptable and would use both in the future. CONCLUSIONS: A pocket feedback card and dedicated feedback session improved the quantity and quality of feedback delivered to IM residents by their attendings on the inpatient wards. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22038842 [PubMed - as supplied by publisher]

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Severe acute hypertension among inpatients admitted from the emergency department.

J Hosp Med Start a Discussion »

Nov 012011

Severe acute hypertension among inpatients admitted from the emergency department.

J Hosp Med. 2011 Oct 28;

Authors: Shorr AF, Zilberberg MD, Sun X, Johannes RS, Gupta V, Tabak YP

Abstract
BACKGROUND: Hospitalists often treat patients with severe acute hypertension (AH) presenting to the hospital. Little is known about the epidemiology of this syndrome. OBJECTIVE: To examine the prevalence of severe AH in patients admitted through the emergency department (ED) and its associated outcomes. DESIGN: A cohort study using retrospectively collected vital signs and other clinical data. PATIENTS: A total of 1,290,804 adults admitted between 2005 and 2007. SETTING: One hundred fourteen acute-care hospitals. MEASUREMENTS: Severe AH was defined as at least 1 systolic blood pressure (SBP) >180 mmHg. We used multivariable regression to estimate AH-attributable in-hospital mortality, need for mechanical ventilation (MV), and length of stay (LOS). RESULTS: Severe AH occurred in 178,131 (13.8%) patients. Disease categories with the highest prevalence were nervous (29.0%), circulatory (16.0%), endocrine (14.7%), and kidney/urinary (13.5%). The overall in-hospital mortality was 3.6%. The relationship between severe AH strata and mortality was graded for nervous system diseases; mortality rates for each 10 mmHg increase in SBP from 180 to >220 mmHg were 6.5%, 8.1%, 9.9%, 12.0%, and 19.7%, respectively (P < 0.0001). The relationship between severe AH strata and need for MV was graded in the most pronounced way in respiratory and circulatory conditions (P < 0.0001). The relationship between severe AH strata and LOS was graded in most disease categories (P < 0.0001). CONCLUSIONS: Severe AH appears common and its prevalence varies by underlying clinical condition. Severe AH is associated with excess in-hospital mortality for patients with nervous system diseases and, for most disease categories, prolongs hospitalization. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22038891 [PubMed - as supplied by publisher]

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Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: A survey of healthcare professionals.

J Hosp Med Start a Discussion »

Nov 012011

Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: A survey of healthcare professionals.

J Hosp Med. 2011 Oct 28;

Authors: Lloyd NS, Douketis JD, Cheng J, Schünemann HJ, Cook DJ, Thabane L, Pai M, Spencer FA, Haynes RB

Abstract
OBJECTIVE: Deep vein thrombosis (DVT) prophylaxis remains underused in hospitalized medical patients despite strong recommendations that at-risk patients should receive prophylaxis. To understand this gap between knowledge and practice, we surveyed clinicians' perceptions about the importance of DVT prophylaxis, barriers to guideline implementation, and interventions to optimize prophylaxis. METHODS: Paper- and electronic mail-based surveys were sent to 1553 internists, nurses, pharmacists, and physiotherapists in Ontario, Canada. Responses were scored on 7-point Likert scales. An important barrier to optimal DVT prophylaxis was 1 with a mean score ?5, and interventions with high potential success or feasibility were those with mean scores ?5. RESULTS: DVT prophylaxis was perceived as important by all clinician groups but this did not appear to translate into knowledge about underutilization of current DVT prophylaxis strategies. Physicians and pharmacists recognized the underuse of DVT prophylaxis in medical patients, while nurses and physiotherapists tended to perceive prophylaxis strategies as appropriate. Lack of clear indications and contraindications for prophylaxis and concerns about bleeding risks were perceived as important barriers. Preprinted orders were considered the most potentially successful and feasible way to optimize prophylaxis. CONCLUSIONS: A considerable barrier to optimal DVT prophylaxis utilization may be that those healthcare providers best able to conduct a daily assessment of patients' need for prophylaxis underrecognize the problem that prophylaxis is underutilized in this population. Interventions to bridge the gap between knowledge and practice should consider preprinted orders outlining DVT risk factors, and educating front-line care providers prior to implementation of a top-down approach. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22038793 [PubMed - as supplied by publisher]

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Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis.

Crit Care Med Start a Discussion »

Nov 012011

Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis.

Crit Care Med. 2011 Oct 27;

Authors: De Backer D, Aldecoa C, Njimi H, Vincent JL

Abstract
OBJECTIVES:: There has long-been controversy about the possible superiority of norepinephrine compared to dopamine in the treatment of shock. The objective was to evaluate the effects of norepinephrine and dopamine on outcome and adverse events in patients with septic shock. DATA SOURCES:: A systematic search of the MEDLINE, Embase, Scopus, and CENTRAL databases, and of Google Scholar, up to June 30, 2011. STUDY SELECTION AND DATA EXTRACTION:: All studies providing information on the outcome of patients with septic shock treated with dopamine compared to norepinephrine were included. Observational and randomized trials were analyzed separately. Because time of outcome assessment varied among trials, we evaluated 28-day mortality or closest estimate. Heterogeneity among trials was assessed using the Cochrane Q homogeneity test. A Forest plot was constructed and the aggregate relative risk of death was computed. Potential publication bias was evaluated using funnel plots. METHODS AND MAIN RESULTS:: We retrieved five observational (1360 patients) and six randomized (1408 patients) trials, totaling 2769 patients (1474 who received norepinephrine and 1295 who received dopamine). In observational studies, among which there was significant heterogeneity (p < .001), there was no difference in mortality (relative risk, 1.09; confidence interval, 0.84-1.41; p = .72). A sensitivity analysis identified one trial as being responsible for the heterogeneity; after exclusion of that trial, no heterogeneity was observed and dopamine administration was associated with an increased risk of death (relative risk, 1.23; confidence interval, 1.05-1.43; p < .01). In randomized trials, for which no heterogeneity or publication bias was detected (p = .77), dopamine was associated with an increased risk of death (relative risk, 1.10; confidence interval, 1.01-1.20; p = .035). In the two trials that reported arrhythmias, these were more frequent with dopamine than with norepinephrine (relative risk, 2.34; confidence interval, 1.46-3.77; p = .001). CONCLUSIONS:: In patients with septic shock, dopamine administration is associated with greater mortality and a higher incidence of arrhythmic events compared to norepinephrine administration.

PMID: 22036860 [PubMed - as supplied by publisher]

Link to Article at PubMed

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