According to the American College of Chest Physicians (ACCP) guidelines thrombolytic therapy is not recommended for most patients (grade 1B). One reason is that controlled clinical trials have not demonstrated benefits in term of reduced mortality rates or earlier resolution of symptoms when currently compared with heparin. Another reason is that thrombolysis with tPA carries a substantial risk for severe complications like intracerebral haemorrhage. Currently accepted indications for thrombolytic therapy include hemodynamic instability or right ventricular dysfunction demonstrated on echo.
Although not scientifically proven, quite a few cardiologists will argue that thrombolysis will benefit in better clinical long term outcome by experience. The question remains whether thrombolysis is underutilized and might improve outcomes in moderate PE’s as well.
In this publication in Clinical Cardiology Mohsen at al. present an interesting concept of applying a ‘safe dose thrombolysis’ (SDT) where half the dose of tPA is given in conjunction with a modified dose of parenteral anticoagulation... rivaroxaban in this case. Over 12 months 98 patients with moderate to severe PE were treated with this regimen. They come to the conclusion that safe dose thrombolysis plus rivaroxaban was highly safe (no bleeds, recurrent VTE in 3 patients) and effective, leading to favorable early and intermediate-term outcomes and early discharge.
Despite some limitations in this publication the idea is interesting indeed and might be a first step towards a new approach towards thrombolysis.
Sharifi M et al. Clin Cardiol. 2014 Feb;37(2):78-82
Queshi at al. have published a nice retrospective cohort study in order to answer the question if you should restart anticoagulation in patients with atrial fibrillation (AFib) after an event of gastrointestinal bleeding (GIB). If yes, will I harm the patient by doing so and when should I restart anticoagulation?
In five years (2005-2010) 1329 patients developed major GIB. In 49.1% of these patients Warfarin was restarted and this was associated with decreased thromboembolism and reduced mortality. They were able to show that restarting Warfarin after 7 days was not associated with increased risk of GIB, but also reduced risk for thromboembolism and death compared to resume after 30 days of interruption.
So, according to these data it seems safe to restart anticoagulation in these patients 7 days after a major GI bleed... and you even seem to do something good for your patient!
Qureshi et al. Am J Cardiol. Nov 2013
In 2002 two published articles in the New England Journal of Medicine changed ICU management of out of hospital arrests profoundly. According to these two articles (cited below) the American Heart Association labeled this to be good evidence (Level1) to recommend induced hypothermia in comatose survivors of out of hospital cardia arrest caused by VF. The target temperature was recommended to be between 32-34°C and to be maintained for 12-24 hours.
And now this... Nielsen et al. present the Targeted Temperature Management Trial showing, that there is NO difference between patients cooled to 33°C and patients kept at 36°C. Is this the end of the cooling era, should we change our management?
I personally think think that this trial basically adds up to our knowledge in the field of post cardiac arrest care, but not necessarily contradicts the previous two trials. We now have one trial showing that there seems to be no difference between 33°C and 36°C but we also know, that hyperthermia (pyrexia) is troublesome and associated with worse neurological outcome.
So, as pronounced hypothermia (33°C) makes no difference to ‘mild’ hypothermia (36°C) and pyrexia is proven to be harmful... the question is: What is the right temperature? We seem to head towards normothermia or mild hypothermia in order to provide best management for our patients. It’s going to be interesting to see how recommendations will change in the near future.
The Targeted Temperature Management Trial: Nielsen N, et al. New Engl J Med. 2013 Dec;369(23):2197-206
The 2 trials that introduced therapeutic hypothermia into ICU practice:
The Hypothermia After Cardiac Arrest Study Group, Holzer at al. New Engl J Med. 2002 Feb;346(8):549-556
Bernard S.A. et al. New Engl J Med. 2002 Feb;346(8):557-563
Review article on therapeutic hypothermia for non-VF/VT cardiac arrest:
Sandroni S. et al. Crit Care Med; 2013;17:215
Pyrexia and neurological outcome:
Leary M. et al. Resuscitation. 2013 Aug;84(8):1056-61
The importance of a positive family history for the predisposition to coronary heart disease and myocardial infarction is well established. Erdmann J. et al. describe in their just published Nature article how two seperate mutations in two functional relates genes directly lead to accelerated thrombus formation in the microcirculation. The mutations have been found in a large german family out of which 23 had suffered of a myocardial infarction. Is the answer for further improvement in the treatment of myocardial infarctions maybe in our genes...?
Erdmann J. et al. Nature, November 2013; nature 12722
Inspired by an excellent post by Dr. Pat Nelligan on AnaesthesiaWest we would like to provide even more evidence against routine change of IV catheters... just because you are told to do so for hospital policy reasons.
Brown D. et al. have provided an excellent overview article on this issue. It is clearly shown that peripheral IV catheter should be replaced as clinically indicated, rather than on a routine basis. The level of evidence here is: A. This means that this recommendation of this treatment/ procedure is effective! We add another 3 articles supporting this recommendation. We do many other things on ICU with lower levels of evidence, or even no evidence at all. So it is definitely time to change this bad habit.
So Pat, I won’t do it either... full stop!
Bregenzer T, et al. Arch Intern Med, January 1998; 158(2):151-6
Lee WL, et al. Am J Infect Control, 2009 Oct;37(8):683-6
Lai KK, et al. Am J Infect Control, 1998 Feb;26(1):66-70
Dopamine has been widely used in the past for improving renal function but was abandoned due to lack of evidence and various potential serious side effects. In the new Heart Failure Guidelines 2013 of the AHA.pdf there is an interesting note in the section hospitalized patients with heart failure: low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better improve renal function. The level of evidence is IIb/B which means that efficacy is less well established and that there is greater conflicting evidence from trials. Indeed, when looking at the cited articles more questions than answer remain... but see yourself.
Giamouzis G, et al. .J Card Fail. 2010 Dec;16(12):922-30
Elkayam U, et al. Circulation. 2008 Jan 15;117(2):200-205