IV fluid choice part 2: The SMART trial

A review of the SMART trial (Semler 2018) comparing 0.9% saline to balanced crystalloid

Yesterday, I covered the SPLIT trial, comparing saline with Plasma-Lyte 148. Today we are going to look at SMART, the trial that provoked the numerous cringe-worthy popular headlines…

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IV fluid choice part 1: The SPLIT trial

A review of the SPLIT trial (Young 2015) comparing saline to Plasma-Lyte 148

“The saline used in IV bags could be killing you”, screams the New York Post. CNN seems to agree. Everyone in the world seems to know that saline is evil, but just yesterday I hung a bag of saline when treating a sick septic patient. Is that because I am a bad doctor? Because I haven’t read the studies? Because I don’t care? Or is this just another example of the general rule that headline news describing medical research is almost always wrong?

Those headlines were in response to two studies published in the New England Journal this year: SMART and SALT-ED. I will get to those papers in the next 2 days, but I think we should start with what was previously the largest, and still is the best trial available comparing saline to a balance IV solution. Welcome to IV fluids week…

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Adverse drug reactions in the emergency department (Hohl 2018)

Can a decision tool help us identify patients at risk for adverse drug reactions in the emergency department?

Adverse drug events might be responsible for as many as 1 in 9 emergency department visits.1,2,3 Physicians frequently miss the diagnosis of medication related adverse events.4,5,6 Pharmacists can be very helpful in assessing patients for adverse drug events, but are a scarce or non-existent resource in most emergency departments. This paper asks whether clinical decision tools can help us identify adverse drug reactions among emergency department patients.

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Paramedic 2: Epinephrine harms/helps in out of hospital cardiac arrest

A critical appraisal of the PARAMEDIC 2 trial (epinephrine in out of hospital cardiac arrest)

After years of waiting, PARAMEDIC 2, the large RCT of epinephrine for out of hospital cardiac arrest, has finally been published. So we can now definitively say that epinephrine is harmful. Wait, maybe it helps? Can a positive study demonstrate harm? Maybe this EBM stuff isn’t so easy after all

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Articles of the month (July 2018)

A monthly (ish) summary of the emergency medicine literature

You will probably notice a new format to the articles of the month. I was getting sick of not being able to find papers that I knew I had previously commented upon. Having them listed as one 10 papers in the articles of the month made them very difficult to search for. Therefore, on bigger, more important papers, I have started writing stand alone blog posts. I will still include those papers in the articles of the month, but the summary will be truncated, with a link to the blog for all the details. The articles of the month will probably still contain extra articles, including papers that don’t warrant their own post and my usual “just for fun” kind of papers. Let me know what you think. Continue reading “Articles of the month (July 2018)”

Tamsulosin for kidney stones: The STONE trial

Another randomized control trial of “medical expulsive therapy”

This again? I know I’ve covered tamsulosin for nephrolithiasis a number of times before. I image most people can predict the results of this study. It may seem a bit repetitive, but I think there is an important EBM lesson in this data. Continue reading “Tamsulosin for kidney stones: The STONE trial”

IV fluids do not cause cerebral edema in pediatric DKA (Kuppermann 2018)

Does IV fluid rate or tonicity contribute to the rate of cerebral edema in pediatric DKA?

Some children with diabetic ketoacidosis develop cerebral edema and have bad neurologic outcomes. Unfortunately, when this happens, fingers are frequently pointed at emergency physicians for our overzealous use of intravenous fluids. Children are not little adults, we are told, and cannot tolerate the same volumes of fluids. Or perhaps it is the use of hypotonic fluids. Either way, we are given very strong recommendations to avoid “aggressive” IV fluids, and to avoid hypotonic fluids. (TREKK 2014; Dunger 2004) However, the evidence base for these recommendations is very weak, relying entirely on observational data. (Hom 2008) This observational data indicates an association, but that does not translate to causation. Children receiving more fluids tend to be sicker and more likely to develop cerebral edema in the first place, meaning the association with fluids could be entirely based on confounding. A case control study done in 2001 found no association with volume of fluid resuscitation, but instead with acidosis and renal failure (markers of disease severity). (Glaser 2001) To date, there has been a lot of conjecture, but not a lot of answers. Finally, we have a large, randomized trial to guide our management…

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