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Showing posts from October, 2014

A randomized trial of protocol-based care for early septic shock

Landmark Series
Methodology Score: 4/5      Usefulness Score:  4/5 ProCESS Investigators N Engl J Med. 2014 May 1;370(18):1683-93.
Abstract Link This large multicentre U.S. RCT of 1341 septic patients found no significant differences in mortality amongst the three arms of the study: 21.0% in the EGDT group, 18.2% in the protocol-based standard-therapy group, and 18.9% in the usual-care group. JC attendees appreciated that this study will not change practice at the TOH as it underscores that protocolized treatment has translated to a higher standard of care and thus reinforces our current management of septic patients with emphasis on early recognition, early antibiotics and early/adequate volume resuscitation. By: Dr. Tamara McColl 

Epi lesson: Contamination in Randomized Trials This is a type of bias where there is a mixing of treatments between study groups such that the impact of the intervention is difficult to determine. This is most likely to occur in non-drug trials where the interven…

Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial

Methodology Score: 3/5                  Usefulness Score: 2.5/5 Chamberlain JM, et al; Pediatric Emergency Care Applied Research Network (PECARN). JAMA. 2014 Apr 23-30;311(16):1652-60. doi: 10.1001/jama.2014.2625.
Full Article
This double-blind, multi-center, superiority RCT (N=273) found that first-line treatment of pediatric status epilecticus with Lorazepam IV was not superior to Diazepam IV in seizure cessation (72.9% vs 72.1%) or need for ventilation (17.6% vs 16.0%); Lorazepam was more sedating (66.9% vs 50.0%). The JC group agreed that despite this likely being the best treatment study looking at pediatric status epilepticus, the post-hoc exclusions and the large number of protocol violations undermined its robustness.  By: Jean-Christophe Ghazal (Presented May 2014)

Epi Lesson:Post-Randomization Exclusions It is widely accepted that the primary analysis of data in a randomized clinical trial should compare patients according to the group to which they were randomly allocated, regardles…

2014 Canadian Guidelines for AF Management: Part 2: ED Algorithm and Risk Stratification for Stroke

by Ian Stiell MD @EMO_Daddy

We continue to discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
Clinical experience and published reports support the general belief that it is safe to proceed with cardioversion if the duration of AF/AFL is clearly less than 48 hours and the patient has no high-risk stroke characteristics.