7 Sep - Sepsis Guidelines

Discussion today focused primarily on the early management of sepsis.  This is a condition for which the mortality has not really decreased much since the advent of antibiotic therapy.  A few interventions have been shown to decrease mortality, and there are a core set of interventions that should be considered in all septic patients.

The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock.  They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).

This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline.  The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation.  This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.

As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles.  The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small.  This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia.  If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.

One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis.  A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery.  This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis.  The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients.  These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.

2 Sep Cavitary Lung Disease

This AM covered a case of long-standing progressive cavitary lung disease, due in this case to Mycobacterium avium.  Cavitary diseases of the lung cover a broad range of infectious and non-infectious causes.  Chronicity of the process, associated findings, and epidemiologic history are all necessary to narrow down the possibilities.  If spontaneous sputum does not reveal the offending pathogen invasive diagnostics are often needed, usually starting with bronchoscopy, followed by CT guided needle biopsy, and ultimately VATS / open lung biopsy.

When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears.  Don't wait until they are positive.

Further reading:

Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.

This image from that article shows a MAI cavity very similar to that seen in our patient.

Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure.  These guidelines from the ATS and IDSA cover the topic in depth.

31 Aug - Obstructive Jaundice

Evaluation of elevated LFTs discussed in a recent MR, but topic today was a slightly different scenario.  Obstructive jaundice is often the first sign of a biliary tract malignancy such as cholangiocarcinoma.  Evaluation is aimed at locating the site of the obstruction and the potential resectability of the lesion.

Remember Courvoisier sign - though in the modern era of easily accessed imaging studies and lab tests the diagnosis is often made before this sign develops.

This section from the eMedicine article on obstructive jaundice gives a nice rundown of the strengths and weaknesses of different imaging modalities for evaluating obstructive jaundice.

24 August - Atrial Fibrillation

Here is the article I mentioned on care of patients with atrial fibrillation:

ACP InTheClinic Atrial Fibrillation 2010 update.  Has links to a slideset for use in student teaching as well.

There is also this supplementary toolkit with info on quality measures, guidelines for newly diagnosed a-fib, and patient information material.

You need to be familiar with the findings and limitations of the AFFIRM study, which showed equivalent outcomes between rate and rhythm control strategies, with a potential survival advantage to rate control due to avoidance of antiarrhythmic drug toxicity. 

Also know the results and implications of the RE-LY trial of dabigatran in atrial fibrillation, published in 2009 in NEJM.

23 August - M&m follow up - Critical Thinking

As discussed, this is the book by Groopman titled "How Doctors Think."  There are a couple books with similar/same titles, but this is the one I was talking about.  I will have some curriculum based on this book for Dr Norwood's PGY 1 and 2  courses this year.

Also, this past post from one of my favorite blogs walks through many of the cognitive traps we can fall victim to.  I especially like this gem from his post:

"Ulysses syndrome

Ulysses went from one adventure to another in the odyssey of returning home from the Trojan War. A false positive test can lead to a fruitless odyssey of further investigation: tests lead to more tests, maybe even invasive procedures and harm to the patient. Eventually it is realized that the patient has been healthy all along."

Confirms my adage that imaging begets imaging, tests begets tests, and false positives beget operations.


For additional reading material, this site from Harvard has an extensive bibliography on the topic.  You can not download articles from the site, but paste the titles in google search and you can access most full text articles through the Preston library or on campus.

Acute Renal Failure - RIFLE Criteria

Couple articles to share here to f/u Dr Reddy's MR on renal failure. 

The rifle criteria were established by a concensus conference and are predictive of mortality in acute kidney injury patients:

Risk = 1.5 x increase Cr, GFR down 25%
Injury = 2 x increase Cr, GFR down 50%
Failure = 3 x increase Cr, GFR down 75%
Loss = complete loss for 4 weeks
ESRD = complete loss for 3 months

When managing patients at risk of or in early stages of ARF, this article from AFP has a nice review of the evidence for different interventions.

Back From Vacation - Blog Updates from Recent Topics Week of Aug 1 - 5

Aug 3rd - Evaluation of Cognitive Impairment / Acute Delirium

Hallmark of delirium is fluctuating course with impaired concentration.  My favorite mnemonic to remember causes is I WATCH DEATH, as it also helps remind me what an ominous condition this is.

This site from Vandy has a rundown of that as well as other mnemonics to help with delirium.

Aug 4th - Resuscitation from Lower GI Bleeds.

Sometimes catastrophic bleeding, but usually less immediately life threatening than upper GI bleeds.  Just remember the mantra "two large bore peripheral IVs" when approaching the resiscitation of any hemorrhage.

As far as transfusion triggers goes, generally a lower threshold hemoglobin is better.  There is also some data from Europe that transfusions increase rebleeding risk, at least in upper GI hemorrhages.  Waiting for the hemoglobin to drop ~7 is probably best, barring signs of impaired oxygen delivery.  There is no convincing evidence that transfusing those with cardiac disease up to hemoglobins of 10 is helpdful, and in fact may be harmful.

Aug 5th - End of Life Care

Not directly related to case discussed, but wanted to share this recent JAMA article on elder abuse and self neglect.  Complex situation without good solutions in may cases.