Chiefs’ Inquiry Corner – 1/17/22

January 17, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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   In November, the 4th update to the Surviving Sepsis Campaign (SSC) guidelines were published. The guidelines incorporate studies over the last 5 years on managing patients with sepsis, while also maintaining emphasis on key principles like early antibiotic administration. Some differences to highlight are: 1) Administering an initial fluid bolus of 30 mL/kg was downgraded from ‘strong’ to ‘weak’ based on the low quality of evidence (however, resuscitation should start immediately!);
2) Balanced crystalloids (like LR) should be used for resuscitation rather than normal saline – made as a ‘weak’ recommendation based on available quality of evidence, the guidelines cite an evolving recognition of potential adverse effects of NS including hyperchloremic metabolic acidosis as part of the rationale;
3) Vasopressors should be initiated peripherally if the alternative is delayed care until a central line is placed;
4) Patients with ongoing vasopressor requirements should receive intravenous corticosteroids (this recommendation was strengthened); however, administration of intravenous vitamin C is explicitly not recommended. These changes are likely to be reflected in the Centers for Medicare & Medicaid Services (CMS) sepsis bundle measures in 2022.

References: Executive summary: Surviving Sepsis Campaign: International guidelines for the management of sepsis and septic shock 2021
  While H. pylori can be diagnosed using a number of methods (both invasive and non-invasive), serologic evaluation for the presence of antibodies is considered unreliable and of minimal utility in a clinical setting. The test has poor sensitivity and cannot differentiate between prior infection or exposure to H pylori and active current infection. In current practice, the urea breath test and stool antigen evaluation are considered the most sensitive and specific tests. That being said, don’t forget that these results can be impacted by proton pump inhibitor use within 2 weeks and antibiotics within the last 4 weeks. Urea breath testing is the most accurate method of detection, with about 90% sensitivity and specificity. Stool antigen testing may be slightly less sensitive, but it performs well in overall low prevalence populations such as in the United States.

References: Noninvasive Diagnostic Tests for Helicobacter pylori Infection
  This distinction all comes down to discrete definitions and terminology. In patients with such variability in p-wave morphology that is thought to indicate varying sites of atrial origin, the distinction lies within the heart rate. Wandering pacemaker refers to patients with a HR ranging from 60-100, while multifocal atrial tachycardia refers to patients with a HR of 100 or greater. Some studies have suggested a stronger association between COPD exacerbations and a diagnosis of MAT if a threshold of 90 bpm is used.  

References: Multifocal Atrial Tachycardia