Critical Care (December 2016)
Research:
AIR: Critical Care Part 1
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
15 comments
Keeney et al.
1. How has reading the article changed your practice? I have started to give dexamethasone to pediatric patients with asthma, and will continue this practice after reading this article.
2. What information had you believed in previously that were debunked by reading this article? N/A
3. What new information did you learn from reading this article? There was no difference in the rates of vomiting at home when comparing routes of dexamethasone administration.
4. What are current areas of uncertainty on this topic that can be potential areas for research? Comparing a single dose of dexamethasone vs a two-day course.
Righini et al.
1. What are some strengths of the study? Important clinical question. If this strategy becomes standard of care would save money as well as spare patients radiation and exposure to contrast.
2. What are the limitations? Some patients were risk stratified using the Geneva score for PE, but in the US the Wells score is more common. Difficult to generalize to the US patient population.
3. What are the main outcomes of the study? The main outcome was “the failure rate of the diagnostic strategy, defined as the rate of adjudicated symptomatic thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative D-dimer test result according to the age-adjusted cutoff.”
4. Does reading this article change your practice? Not at this time. I would not feel comfortable stopping a PE work-up on an older patient if the d-dimer was elevated but less than the age-adjusted cut-off proposed by this paper. I would need to see more literature (preferably US literature) supporting this practice, as well as EM organizations such as ACEP publishing guidelines promoting the use of age-adjusted d-dimers. Also not clear which age-adjusted calculation is superior (age x10 when over 50yrs vs a set cut-off of 750 for all patients older than 75yrs vs other strategies).
Totally agree that if we could get an ACEP, or CHEST guideline giving credence to using age-adjusted d-dimer, I’d be on board.
Righini et all – age adjusted d-dimer
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I’m sure we’ve all been waiting on this for a long time. This study is definitely promising.
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The primary outcome, the one the study was designed for, was the rate of failure of this diagnostic strategy, NOT to assess specifically the outcomes of patients who had d-dimer > 500, but less than age adjusted. That was the secondary outcomes. Just keep that in mind.
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Nevertheless, this new algorithm seems pretty robust.
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Remember that the study doesn’t really say that patients with d-dimer >500 but below age adjusted have ruled out for PE. It just says that they did ok within 3 months. Some of them may have had PE’s, possibly small subsegmental ones, for which treatment is controversial, at least in Europe. Also, perhaps some developed pulm HTN as a result of a missed PE, and had long-term comorbidities or died after 3 months.
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Next step of a large RCT with traditional cut off vs. age-adjusted cut-off diagnostic approach. While the rate of VTE or VTE-related death is likely to be very low as demonstrated in this study, cost savings and adverse events might be shown to be reduced.
Keeney et al. Decadron vs. pred in asthma
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Single dose decadron is something I’m already doing when I work in pedi, along with multiple pedi attendings and fellows.
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However, I’m wondering if I should do a single vs. 2 dose decadron.
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And why wouldn’t this also work in adults?
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Keeney et al:
◾How has reading the article changed your practice?
I will use IM/PO decadron for mild/moderate asthma exacerbations in the Pedi ED.
◾What information had you believed in previously that were debunked by reading this article?
It didn’t really debunk anything for me. I’m working in Peds right now and we’re using 1 dose of decadron for asthma exacerbations.
◾What new information did you learn from reading this article?
Honestly, I hadn’t realized that vomiting is such a common problem with prednisone. It’s nice to know that decadron has a decreased risk of vomiting.
◾What are current areas of uncertainty on this topic that can be potential areas for research?
Like Alex said – would this also work in adults? And is there any difference in efficacy of 1 vs 2 doses of decadron, or IM vs PO decadron.
Keeney et al:
Practice change — will more consistently order IM/PO decadron. That said, I am currently (currently as in right now) at Children’s and just tried to do that and was told not to because that’s not standard of care, so maybe not.
Debunked info — none.
New info — agree with Lauri, I definitely didn’t realize the association with vomiting and pred. Will be nice to be able to tell parents that as a warning when I do want to give it (whether for asthma or something else).
Future research — precise dosing, are there patients who this doesn’t work as well in? And I agree with everyone about wanting to do this in adults.
ADJUST-PE
1. Strengths: Multicenter, multinational. I like that they used their own retrospectively derived and validated D-dimer cutoffs. Study was powered enough to assess age-adjusted cutoff failure in pts >500 but below age adjusted PE risk.
2. Prospective study (ie, not RCT). Two different pretest probability assessment tools used. Six different quantitative high sensitivity D-dimers. Although CTPA was used as a confirmation study, the clinical utility of positive CTPA showing isolated subsegmental PE is unclear.
3. Using age-adjusted D-dimer cutoffs in ED patients with suspected PE increased diagnostic yield of D-dimer testing.
4. Probably not. Promising study but given that a positive D-dimer is <300 at BMC (unclear which assay?), I’m ok w/ playing it conservative given the consequences….and I’m a 2nd year resident.
Dex article:
The option to provide a tx regimen that leads to better compliance is often a game changer, particularly in prevalent diseases. Although I tend to be one who doesn’t stray too far from common practices, I would definitely consider adapting my approach to steroids in asthma exacerbations considering the positives. The only things that I would like to see more of are studies looking at the side effects, negative outcomes, etc. Unscheduled visits and vomiting are both good but I’d like to see a little more to limit risk. Additionally, I was unaware of the extent to which dex has a longer half-life and lower incidence of vomiting vis-à-vis prednisone. I’d like to see more research into negative outcomes (medical but also utilization of services) and studies on costs differential. And why aren’t we trying this in adults?
ADJUST- PE
1.What are some strengths of the study? Multinational, multicenter study. As Andrew said, this is an important, clinically relevant topic that we think about all the time. If every center adopted an age-adjusted cut off we could cut CTPA usage drastically.
2. What are the limitations? Multiple assays and 2 different clinical decision instruments were used. Not randomized study – no control group, no comparison b/w cohorts, minimal autopsies, subsegmental PEs considered inconclusive
3. What are the main outcomes of the study? Basically patients with a clot but were ruled out using an age-adjusted d-dimer
4. Does reading this article change your practice? I believe we need a protocol using the age-adjusted d-dimer. Though it seems when this idea is brought up on shifts, we are hesitant to use the evidence.
Alex, I hear you on the guidelines from CHEST or ACEP. Of note, the ACP (IM) has embraced the age-adjusted d-dimer in their clinical guideline (which was written with 2 EM docs on the committee). http://annals.org/aim/article/2443959/evaluation-patients-suspected-acute-pulmonary-embolism-best-practice-advice-from
More FOAM resources – http://www.emdocs.net/age-adjusted-d-dimer/
Wow that’s exciting stuff from ACP.
Re: dexamethasone use in asthma patients. I spoke to one of the Children’s ED attendings about this topic. She does not embrace dexamethasone for asthma patients yet. She thinks the studies were not properly powered and also that the dosing regimens varied widely across studies. She also thinks that mild asthma might need different dosing than moderate asthma. She says that until there is a well-done study that looks separately at mild asthma vs moderate asthma dosing regimens, she will not use dexamethasone particularly because we already have a therapy (prednisolone) that is proven to work. An interesting perspective.
Cool stuff Andrew!
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IMO, in terms of dosing regimen variability, an extra dose of decadron is really no big deal in terms of extra side effects for kids. And treating mild asthma with lower doses of steroids really doesn’t lower the risks of complications since there are essentially little to no risk already.
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So why not just give the higher dose, of pred or decadron, unless there are obvious contraindication.
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And if decadron ends up being equivalent, the easier dosing schedule certainly is a big help.
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Really appreciate the follow up Andrew.
Righini et al
1. I thought the study was very thoughtfully designed and carried out, and their conclusions are supported by the results of their study
2. As Alex pointed out, the study actually measured the rate of failure of the age-adjusted d-dimer strategy, not the outcomes
3. That it is safe to use an age-adjusted d-dimer to rule out PE
4. Not at this moment as I don’t think our assays are the same (so wouldn’t know how to correctly age-adjust ours!) BUT, I think it’s a great idea and I would hope for more research in the future (so that I can use it when I’m an attending!)
Keeney et al
1. I really like the idea of using dex for asthma – if efficacy is the same it’s a much easier medication regimen with potentially less side effects
2. Nothing
3. That oral prednisone causes vomiting
4. Efficacy in adults – I’ve actually used it on several occasions for adults, and there are new studies coming about on this (https://www.sciencedaily.com/releases/2016/04/160427150900.htm, https://www.ncbi.nlm.nih.gov/pubmed/27117874)