Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician

Empagliflozin-induced Diabetic Ketoacidosis Unmasking a Type 1 Diabetes Diagnosis

Empagliflozin is a sodium glucose cotransporter-2 inhibitor that inhibits renal glucose reabsorption through an insulin-independent mechanism. This class of drugs is used in the management of type 2 diabetes. A 49-year-old female with type 2 diabetes treated with empagliflozin presented to the emergency department in diabetic ketoacidosis (DKA). This case report details the series of events leading to the diagnosis of drug-induced DKA, which led to a change in the patient’s diagnosis from type 2 diabetes to type 1 diabetes

Expanding HIV Screening in the UNMH Emergency Department

Introduction: Access to HIV screening and care may be limited in resource-constrained health care settings. The CDC recommends routine HIV screening for all patients aged 13-64 years, unless the prevalence of undiagnosed HIV in that population has been documented to be New Mexico is ranked 34th in the US for the rate of HIV diagnoses made per year—among the lowest of all 50 states. Meanwhile, NM is ranked 4th for chlamydia, 22nd for gonorrhea, and 20th for syphilis [3]. This discrepancy in sexually transmitted infection rates suggests the possibility of underdiagnosis of HIV infection in NM and, as a result, underestimation of the actual HIV prevalence in the state. As part of an initiative to improve HIV preventive care for UNMH Emergency Department (ED) patients evaluated after a sexual assault [4], we implemented rapid HIV screening that was also available to all UNMH ED patients at risk for HIV, regardless of the reason for their ED visit. This initiative had the secondary benefit of improving HIV screening rates in the ED. Materials/Methods: Two domains for broad infrastructural improvement were identified: (1) the availability of rapid HIV screening in settings where this test could impact decision-making and (2) the connection to outpatient follow-up care for patients at high risk for or diagnosed with HIV. Barriers to improvements included the lack of a mechanism to perform confirmatory testing for all positive rapid screens and the lack of streamlined access to follow-up outpatient care. Through extensive collaboration with stakeholders throughout the health system, we implemented rapid HIV screening in the UNMH ED, a reflex laboratory confirmatory test, and nurse-driven protocols for follow-up of confirmatory testing. In collaboration with partners at UNM and in the community, we established a network of HIV care clinics and a 24/7 connection to care phone line to improve access to care for patients diagnosed with HIV infection. A REDCap “tracker” tool was devised to allow outpatient clinics to report, without any identifiable patient information, whether they saw patients in follow-up. Results: This project resulted in several improvements: (1) Rapid, point-of-care HIV screening is now available in the UNMH adult and pediatric EDs and has subsequently been expanded to UNMH Labor and Delivery. (2) Reflex laboratory confirmatory testing for any positive rapid HIV screen has been implemented, and a nurse-driven protocol for follow-up of these results is in place. (3) A 24/7 Truman Health Services “connect-to-care” phone line is available to providers at UNMH and in the surrounding community to link point-of-care evaluations with outpatient follow-up for patients with a new HIV diagnosis. (4) A network of seven follow-up clinics for HIV treatment and ten follow-up clinics for HIV preventive care in the Albuquerque area is now available to UNMH patients. Utilizing the REDCap “tracker” tool, we can confirm that patients are following up in outpatient clinics. Conclusion: The project was successful in establishing rapid, point-of-care HIV testing in the ED and in streamlining follow-up care for patients newly diagnosed with HIV. The success of the ED screening initiative led to expansion of the rapid testing elsewhere at UNMH. Future plans are in development to quantify the change in HIV screening rates resulting from these improvements using an interrupted time series study design. References: 1. Branson, Bernard, M, and et al. “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.” CDC. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm 2. Moyer, VA. “Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement.” Ann Internal Medicine 159, no. 1 (2013): 51–60. 3. “National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. New Mexico - State Health Profile,” https://www.cdc.gov/nchhstp/stateprofiles/pdf/New_Mexico_profile.pdf. 4. Saadatzadeh T, Wilson CG, Salas NM, Walraven C, Sarangarm P, Crandall CS, Crook J, Sarangarm D, Yaple C, Stafford A, Page K, Carvour ML. The IN-STEP Project: Improving Access to HIV Prevention for Patients Evaluated After Sexual Assault Using a Multidisciplinary, Patient-Centered Approach. Poster presented at University of New Mexico Health Sciences Center Quality Improvement and Patient Safety Symposium in February 2019, Albuquerque, NM and the New Mexico HIV & HCV Update Conference in April 2019, Albuquerque, NM. Oral presentation by T. Saadatzadeh at the American College of Physicians Internal Medicine Annual Meeting in April 2019, Philadelphia, PA

Multicenter Retrospective Review of Ketamine Use in the ICU

IMPORTANCE: The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established. OBJECTIVES: To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017. MAIN OUTCOMES AND MEASURES: Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0–24 hours and 25–48 hours after. RESULTS: A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39–65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1–0.5 mg/kg/hr) and continued for 1.6 days (0.6–2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7–72.6%], 0–24 hr: 78.6% [74.3–82.5%], 25–48 hr: 80.3% [74.6–84.3%]; p \u3c 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5–60.0%], 0–24 hr: 64.1% [60.7–67.2%], 25–48 hr: 68.9% [65.5–79.5%]; p \u3c 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25–400], 0–24 hr: 118 [10–363], 25–48 hr: 80 [5–328]; p \u3c 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4–67], 0–24 hr: 6 [0–68], 25–48 hr: 3 [0–57]; p \u3c 0.001), propofol (mg) (24 hr prior: 942 [223–4,018], 0–24 hr: 160 [0–2,776], 25–48 hr: 0 [0–1,859]; p \u3c 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276–1,925], 0–24 hr: 285 [0–1,283], 25–48 hr: 0 [0–826]; p \u3c 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0–47.0%], 0–24 hr: 39.5% [27.0–43.8%], 25–48 hr: 0% [0–43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study. CONCLUSIONS AND RELEVANCE: There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased

High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018–2020

Background: Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs). Methods: We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli. Results: Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41–77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04–3.51, and OR 6.93, 95% CI: 4.95–9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance. Conclusion: FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments