Consider Immediate Trip to Cath Lab for Comatose Cardiac Arrest Survivors Without STEMI.

Acute coronary occlusions were common in comatose cardiac arrest survivors without ST-segment elevation myocardial infarction.
Immediate cardiac catheterization for cardiac arrest survivors with acute ST-segment-elevation myocardial infarction (STEMI) is standard practice, but whether it is beneficial in postarrest patients without STEMI is unclear. Investigators retrospectively analyzed data from 269 comatose adult patients at six U.S. medical centers who were treated with therapeutic hypothermia after cardiac arrest due to ventricular arrhythmia without evidence of STEMI on electrocardiogram (ECG).

Of 269 patients, 45% received early cardiac catheterization (either at hospital admission or during hypothermia treatment), 15% received catheterization later during hospitalization, and 39% did not receive catheterization. The early-catheterization group was more likely to be in shock on admission and to receive mechanical support (usually with an intraaortic balloon pump), aspirin, antithrombin agents, and glycoprotein IIb/IIIa inhibitors than patients who received later or no catheterization. Acute coronary occlusion was present in 26% of the early-catheterization group and 29% of the late-catheterization group.

Overall hospital mortality rate was 43.5%. Patients who received early catheterization were significantly more likely to survive than those who received late or no catheterization (66% vs. 49%) and to have good neurologic outcome (61% vs. 45%). Differences in outcomes were even more striking when the early-catheterization group was compared to the no-catheterization group.


Given that the post-resuscitation electrocardiogram may be unreliable and ST-elevation is insensitive for predicting acute coronary occlusion, it is reasonable to consider immediate cardiac catheterization for comatose survivors of arrhythmia-induced cardiac arrest, even in the absence of STEMI.

Source: NEJM

Ultrasound Guidance Significantly Lowers Risk for Failed Lumbar Punctures and Epidural Catheterizations.

The failure rate was 1% with ultrasound and 7% with standard palpation of landmarks.

Lumbar puncture (LP) is performed for diagnostic purposes (e.g., analysis of cerebrospinal fluid [CSF]) and for drug delivery, and epidural catheterization is performed to administer anesthetics. But sometimes these procedures fail. In this meta-analysis of 17 randomized, controlled trials involving 1300 patients, investigators determined whether ultrasound (US)-guided imaging, compared with standard palpation of anatomical landmarks, can lower risk for failed LPs or epidural catheterizations.

Five studies evaluated LP and nine evaluated epidural catheterization. Failed LP was defined as lack of CSF return; failed epidural catheterization was defined as inability to place an epidural catheter, need for intraoperative analgesia, or need to replace the catheter. Overall, 1% of procedures failed in the US group, compared with 7% in the standard-technique group. US-guided imaging was associated with significantly lower risk for both failed LP and failed epidural catheterization (risk ratio, 0.20 for each). Likewise, US-guided imaging significantly reduced the number of traumatic procedures (defined as “visible blood aspiration or a red blood cell count” in the CSF), insertion attempts, and needle redirections.

Comment: Unsurprisingly, use of ultrasound-guided imaging during lumbar puncture and epidural catheterization decreased the chances of adverse outcomes. The authors conclude that US-guided imaging could “be a useful adjunct” for these procedures, particularly in settings where they are commonly performed (e.g., obstetrics) or “where failure is associated with particularly negative consequences” (e.g., pediatrics).


Source: Journal Watch General Medicine

Replacing IV Catheters Only When Clinically Indicated Seems Safe .

Replacing peripheral intravenous catheters only when clinically indicated (for example, after accidental removal or infiltration) causes no more complications than replacing them according to standard time-based schedules, according to a Lancet study.

Researchers randomized some 3300 adult patients to have their intravenous catheters replaced every third day or only as clinically indicated. The rate of phlebitis, the primary outcome, was identical in the two groups, at 7%. Secondary outcomes, such as rates of catheter colonization and all-cause bloodstream infections, were also similar between groups.

The authors calculate that, on average, clinically indicated replacement would extend catheter use by a single day, and that one in every five patients would avoid an unnecessary procedure. They estimate that the reduction in staff time and other costs could save the U.S. $60 million in healthcare costs annually.

Source: Lancet