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A group of 19 critical care gurus changed the game on sepsis acronyms this week. Their brainchild: The Third International Consensus Definitions on Sepsis and Septic Shock.
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SOFA and qSOFA, as in the Sequential Organ Failure Assessment and its q for 'quick' companion. SOFA is a 0 - 24 point scale that measures six criteria for organ failure in ICUs. qSOFA is its easy to remember sidekick, which checks patients for altered mental status, respiratory rate > 22 / min, and systolic blood pressure < 100 mm Hg. If your patient meets 2 of the 3 qSOFA criteria and you think they're infected, go ahead and call it sepsis.
JAMA
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RIP, SIRS criteria. The task force says SIRS is present too frequently in non-infected hospitalized patients. SOFA is better than SIRS at predicting in-hospital mortality, making prompt recognition of positive SOFA scores a big deal. In the ICU setting, the SOFA score predicts in-hospital mortality about as well as other, more complex scores. Outside of the ICU, the qSOFA is now the preferred assessment tool. The sepsis acronyms the authors considered are listed here.
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The gurus put their heads together and decreed that the term 'septic shock' applies to patients that need vasopressors to maintain a mean arterial pressure above 65 mm Hg and have a serum lactate greater than 2 mmol/L (>18 mg/dL). Check out this diagram to see how the new definitions fit together.
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Oh boy. If you spent half your med school days getting pimped about SIRS criteria, we feel you. And if you’re not sure any of the documented respiratory rates in your hospital are real, we get that, too. The whole point of the new definitions is to recognize who's truly sick, faster, so that these patients can get the attention they need.
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WHEN YOUR SCRUBS GET GUNKED WITH UNSAVORY MATERIAL
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Time to hold them out of the rotation. Traditionally aspirin is held from the rotation 5 - 7 days before heart surgery to reduce bleeding risk, even though some studies suggest continuing aspirin may reduce the risk of post-op heart attacks. This week, a 2,000 person randomized trial found that continuing low-dose aspirin prior to surgery did not increase the risk of death, bleeding, or need for subsequent re-operation. Cardiac pre-op templates may be due for an update soon.
NEJM
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WHEN YOU THINK YOUR NEW CLINIC OUTFIT IS GETTING SOME BUZZ
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Be wary of style over substance. PCSK9 inhibitors (alirocumab and evolocumab) get a lot of attention for squashing LDL cholesterol levels, but critics point out that the drug efficacy studies are not designed to measure long-term impact on cardiovascular disease. A prospective study of 4000 participants showed that circulating serum PCSK9 concentration is associated with future risk of CVD even after adjustments were made for established CVD risk factors. The results serve as more circumstantial evidence linking PCSK9 to heart disease.
Circulation
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WHEN YOU HAVE AN OPEN SPOT ON YOUR LIST, AND THE ADMISSIONS OFFICE DOESN'T NOTICE
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Listen: sometimes things are less obvious than they appear. An epidemiological study in 50 countries showed that the prevalence of Acute Respiratory Distress Syndrome among ICU admissions was 10%, but mild cases were only recognized clinically 50% of the time. Clinicians did better when ARDS was severe – almost 80% recognition – but appropriate treatment (i.e. low tidal volumes) was instituted in less than 66% of cases. With an ARDS mortality rate upwards of 40%, there's still a lot of work to do.
JAMA
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WHEN YOUR SIGNIFICANT OTHER IS NUDGING YOU FOR COMMITMENT
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Time to try out some rings. A monthly vaginal ring with dapivirine, a non-nucleoside reverse transcriptase inhibitor, reduced HIV infection rates by 27% in a multi-center RCT in Sub-Saharan Africa. Adherence rates were higher with the ring than with vaginal gels and oral medication, both of which did not show benefit as pre-exposure prophylaxis agents in a prior study. Women under age 21 had more trouble with ring adherence, and they did not see a treatment benefit.
NEJM
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Affects between 5 - 10% of people globally. Symptoms are any combination of epigastric pain, early satiety, or excessive fullness during or after meals. Don't rush to endoscopy unless alarm symptoms are present, and make sure to test for H. pylori infection in high prevalence areas. Therapies such as proton pump inhibitors and motility agents have not worked as well as hoped.
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For GI prophylaxis in the ICU? Old guidelines recommend stress ulcer prophylaxis for patients with coagulopathies, GI ulcers in the last year, those admitted with traumatic injuries or burns, and those expected to be intubated for over 48 hours. A 2015 study found that less than 3% of ICU patients experience clinically relevant GI bleeding. An analysis of participants showed that those with three or more medical comorbidities were at greatest risk for bleeding.
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WHAT YOUR PUBLIC HEALTH FRIENDS ARE TALKING ABOUT
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Can there be too much Zika virus? This week the CDC explained Zika's role between the sheets. What we know: men can spread the virus to their sexual partners. Unknowns include how long the virus can be present in semen, if women can spread the virus through sex, or if the virus can be spread through oral sex. The agency advised pregnant women to use protection or abstain from sex with men who have returned from Zika hot spots.
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