Primecuts – This Week in the Journals

February 22, 2017

PrimeCuts 6 min read

kidney 1By Matthew Gross, MD

Peer Reviewed

Risk of Acute Kidney Injury After Intravenous Contrast Media Administration

This single center retrospective cohort analysis intended to assess the risk of contrast- induced nephropathy (CIN) in patients receiving CT scans with IV contrast in the emergency department. The authors responsible for the study recognized that the majority of studies evaluating contrast- induced nephropathy were conducted in patients undergoing arterial angiography and were done before low- and iso-osmolar contrast were available. This study identified a large number of patients via chart review who were over the age of 18 with baseline serum creatinines of 0.4 – 4.0 mg/dl (5499 who underwent CT with IV contrast in the ED and 5234 undergoing CT without). Patients included in the study had their serum creatinine measured within 8 hours of receiving IV contrast and then again 48-72 hours after. They were followed up 6 months later and had their creatinine levels repeated at that time. Patients were excluded from the study if they had a baseline creatinine of 4.0 or greater, had a previous CT with contrast within 6 months, or were renal transplant recipients. After controlling for age, sex, race, initial serum creatinine, estimated initial GFR, comorbidities (including DM, HTN, HIV, CHF, CKD), and acute illness, multivariate analysis found no significant difference in the incidence of acute kidney injury (AKI) at 48-72 hours or chronic kidney disease (CKD) at 6 months between the two groups. While this study is very comprehensive and well done in many ways, it is limited by the fact that only a small fraction of the studied population had a baseline creatinine of 2.0 or more. It is also limited by its single center design, the fact that the majority of those selected were sick enough to be hospitalized (given the necessary 48-72 hour follow up creatinine level), and its lack of control for the type of CT study performed. Despite its limitations, however, this study does show that receiving IV contrast is not correlated with a higher instance of AKI or CKD. While the significant population skew towards lower baseline creatinine and the fact that the type of CT was not controlled for may give reason to pause, this study may make contrast containing CT scans more palatable in instances where contrast would provide significant benefit. 1

Addressing the Fentanyl Threat to Public Health

This prospective piece provides interesting insight into the fentanyl problem currently plaguing illicit drug markets both within the US and abroad. The authors describe how in addition to its use for conscious sedation, short term analgesia, and management of chronic pain, fentanyl is a cheap and easily manufactured high potency cutting agent that has been used with increasing frequency in black market drugs. Fentanyl is 18 times cheaper to produce per kilogram than heroin and has found its way into heroin as well as MDMA and counterfeit oxycontin, alprazolam and acetaminophen/hydrocodone. While heroin cut with fentanyl is becoming a better-known entity for heroin users, its inclusion in other drugs may be taking users by surprise. This unexpected inclusion is thought to be contributing to the increasing number of fentanyl related overdoses. This article argues that enhanced efforts to educate the public about fentanyl, institute harsher penalties for dealing drugs cut with fentanyl, and increasing the dose of naloxone available in overdose kits may help counteract some of the harm inflicted by its increasing popularity.

While this article raises a number of interesting points regarding the inclusion of fentanyl in the illegal drug market, the initiatives suggested to mitigate harm may not be as solidly founded. Efforts to educate rather than rehabilitate this population seems impractical. While educating patients on addiction is important, the resources spent educating this particular population may be better spent on other approaches to combat addiction. It is also hard to see how stiffening penalties for the sale of fentanyl laced products would do anything but worsen the nation’s problem with incarceration for low level drug offenses. Regardless, the information and opinions offered by this article provide interesting insight into this most unfortunate problem.2

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

This observational cohort study assesses the mortality benefit of early intubation during in-hospital cardiac arrest and finds that intubation within the first 15 minutes of cardiac arrest leads to a decreased rate of survival to discharge and decreased functional outcome. The authors point out that since 2010, the role of intubation has been deemphasized during advanced cardiac life support (ACLS) Hasegawa et al. found that survival decreased in particular among patients who were intubated during pre-hospital ACLS management.3 The primary aim of this study was to determine whether this trend towards decreased survival with early intubation was similar for in-hospital cardiac arrest, and the authors essentially found that it was.

Patients intubated within the first 15 minutes of cardiac arrest were matched to those not intubated. Overall survival to discharge was 3% lower in those intubated early versus those who were not (16.3% vs. 19.4%), and good functional outcome was decreased as well (10.6% vs. 13.6%). Subgroup analysis showed that those intubated within the first 15 minutes of an arrest with a shockable rhythm faired comparatively worse than those intubated during the first 15 minutes of a non-shockable arrest. Subgroup analysis failed to show any groups that benefited from early intubation. 4,5

Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit 

The SOFA score was introduced in 2016 as a possible replacement for SIRS criteria in assessing mortality of ICU patients. This retrospective cohort analysis evaluates the outcome of 184,875 patients admitted to intensive care units in Australia and New Zealand. The goal of the study was to see whether a SOFA score of 2 or more would more accurately predict mortality when compared to the same SIRS score. The SOFA score unlike the SIRS score includes pO2, FiO2, platelet count, GCS, bilirubin, creatinine (or urine output) and degree of hypotension (based on MAP and vasopressor support) to predict mortality. 90.1% of patients studied had an increase SOFA score of 2 or more from their baseline while 86.7% of patients met 2 or more SIRS criteria. SOFA was better able to discriminate in-hospital mortality when compared to service criteria with an area under the curve (AUROC) of 0.753 compared with 0.589 for SIRS criteria. qSOFA – a modified SOFA analysis design for emergency department use fell in between with an AUROC of 0.606.

While this finding is interesting, it is unclear how useful it will be in clinical practice. Prognostication has a role in patient care but it seems unlikely that this score would change management in critically ill patients. With 90.1% or 9 out of 10 ICU patients meeting 2 or more SOFA criteria, the score may capture too many patients to actually be helpful in this context.6

Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use

ED patients who receive care from more liberal opiate prescribers have an increased risk of long term opiate use than those treated by more conservative physicians (odds ratio of 1.3). While intuitive, this finding serves yet another reminder to prescribe fewer opiates in almost all cases. 7

Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes

The unfortunately named STAMPEDE trial evaluates the outcomes of 150 obese patients with type II diabetes randomly assigned to three groups – intensive medical therapy alone, intensive medical therapy + sleeve gastrectomy and intensive medical therapy + gastric bypass. At 5 years, 21% of patients receiving intensive medical therapy alone had a hemoglobin A1c <7.0 compared with 51% and 48% respectively when combined with gastric bypass or sleeve gastrectomy.8

Quality-of-Life Outcomes After Transcatheter Aortic Valve Replacement in an Unselected Population: A Report From the STS/ACC Transcatheter Valve Therapy Registry

This relatively large study uses the Kansas city cardiomyopathy questionnaire to assess baseline, 30 day and 1 year quality of life following transcatheter aortic valve replacement (TAVR). While patients had an average improvement of 31.9 points compared to baseline at 1 year, 1 in 3 patients had poor quality of life outcomes at 1 year. Further assessment is still needed to see how quality of life outcomes compares to surgical repair or replacement.9

Dr.  Matthew Gross is a 2nd-year resident at NYU Langone Medical Center

Peer reviewed by Jennifer Mulliken, MD,  Chief Resident at NYU Langone Medical Center

Image courtesy of Wikimedia Commons

References 

  1. Hinson JS, Ehmann MR, Fine DM, et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Annals of Emergency Medicine 2017. https://www.ncbi.nlm.nih.gov/pubmed/28131489
  2. Richard G. Frank PD, and Harold A. Pollack, Ph.D. Addressing the Fentanyl Threat to Public Health. NEJM 2017:605-7. http://www.nejm.org/doi/full/10.1056/NEJMp1615145
  3. Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. Jama 2013;309:257-66. http://jamanetwork.com/journals/jama/fullarticle/1557712
  4. Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Jama 2017;317:494-506. https://www.ncbi.nlm.nih.gov/pubmed/28118660
  5. Angus DC. Whether to Intubate During Cardiopulmonary Resuscitation: Conventional Wisdom vs Big Data. Jama 2017;317:477-8.
  6. Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA Score, SIRS Criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. Jama 2017;317:290-300. http://journalwise.acponline.org/ArticleView.aspx?UI=73011
  7. Michael L. Barnett MD, Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. NEJM 2017:663-73. http://www.nejm.org/doi/full/10.1056/NEJMsa1610524#t=article
  8. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes—5-Year Outcomes. New England Journal of Medicine 2017;376:641-51. http://www.nejm.org/doi/full/10.1056/NEJMoa1600869
  9. Arnold SV, Spertus JA, Vemulapalli S, et al. Quality-of-life outcomes after transcatheter aortic valve replacement in an unselected population: a report from the STS/ACC Transcatheter Valve Therapy Registry. JAMA cardiology 2017. https://www.ncbi.nlm.nih.gov/pubmed/28146260