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Mar 2, 2018

Back to basics

The story

We wouldn’t dare compare being board resident in the ICU to swimming blindfolded in a shark tank, but the lack of data behind routine clinical decisions can be limiting. New research examines steroids and fluids in the critically ill.

The bags

You've heard since the early days of med school that lactated Ringers is more 'physiologic' than normal saline (NS). Two single center studies put the theory to the test. SMART compared NS with balanced crystalloids (lactated Ringer's or Plasma-Lyte A) in 15,800 ICU patients, while SALT-ED compared the two in 13,000 noncritically ill ED patients. In both trials major adverse kidney events within 30 days – a composite of death, new dialysis, or persistent renal injury – were about 1% less common with balanced crystalloids. If the difference seems tiny, remember that over 200 million liters of NS are given each year in the US.
NEJM

The adjunct

Many centers use steroids to dampen the dysregulated host immune response in septic shock, but trials evaluating hydrocortisone as adjunct therapy in shock have produced mixed results. Australia's ADRENAL trial, the largest to date in a complicated literature, compared continuous infusion hydrocortisone to placebo in 3,800 mechanically-vented shock patients. While hydrocortisone failed to improve 90-day mortality, patients in the treatment group had faster resolution of shock by about one day.
NEJM

The combo

APROCCHSS compared combined hydrocortisone and fludrocortisone – included to increase vascular tone – to placebo in 1,200 patients with septic shock. Treatment improved 90-day mortality compared to placebo (43% vs. 49%, respectively) and increased organ-failure free and ventilator-free days. Experts think a mortality benefit was evident in APROCCHSS because the trial enrolled more tenuous patients. Patients had higher rates of positive blood cultures, pneumonia, and overall mortality compared to ADRENAL participants.
NEJM

Say it on rounds

When your alarm goes off at 5 am for a twelfth straight day

Work from home? A randomized trial of 1,200 primary care patients in the UK found that self-titration of blood pressure meds via either self-monitoring or telemedicine reduced systolic blood pressure (SBP) by about 3.5 mm Hg compared to titration in clinic. Over 12 months, patients in the at-home monitoring groups reached BP targets faster than their clinic group counterparts. If sustained, the reduction in SBP would be expected to lower coronary heart disease risk by about 10% and stroke risk by 20%. 
Lancet

When even your golden weekend is a scramble

Take your time. A study of health insurance data from 60,000 patients with type 2 diabetes in Japan found that those who self-identified as fast eaters were 42% more likely to be obese than those who identified as slow eaters and 29% more likely than normal speed eaters. Bedtime within two hours of eating and snacking after dinner were also associated with a higher risk of obesity. 
BMJ Open

Brush up

Infectious diarrhea

Like cancelling your evening plans because you're stuck at work, acute diarrhea is never fun but all too common. About one third of cases are attributed to food. In the United States, Norovirus is the most common culprit, followed by Salmonella and Campylobacter. Focus treatment on fluid and electrolyte repletion. Most patients will not need antibiotics, but consider empiric therapy for those with high-grade fevers and profound volume depletion.

Get meta

With anti-motility agents and infectious diarrhea. A 2008 analysis of 9 studies found that loperamide (Imodium) and antibiotics shortened duration of illness by one day in traveler’s diarrhea compared to antibiotics alone. While anti-motility agents are trending towards earlier use in acute diarrhea, avoid use if concerned for systemic infection or dysentery. Bismuth salicylate (Pepto) remains a safe alternative, if you're trying to offer more than just words of encouragement from outside the bathroom.

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