2014 - March R3 Journal Review
He J et al. Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke: the CATIS Randomized Clinical Trial. JAMA 2014; 311: 469-470. This multicenter, single-blinded, randomized clinical trial looked at the effect of antihypertensive treatment in patients with acute ischemic stroke. The objective was to evaluate whether immediate blood pressure reduction in patients with acute ischemic stroke would reduce death and major disability at 14 days or hospital discharge. 2038 patients were randomly assigned to receive either antihypertensive treatment aimed at lowering SBP by 10-25% within first 24 hours or no antihypertensive treatment at all. The treatment group also had a goal of achieving SBP <140 within 7 days. The treatment group at 24 hours had an average reduction of SBP of 12.7% compared to 7.2% in control group, and a 7 day SBP of 137 compared to 146 in the control group. The results showed that there was no statistical difference in mortality or major morbidity at 14 days or hospital discharge. At three months there was still no significant difference, but a slight trend in reduction of recurrent strokes the treatment group. The major limitation in the study was that patients with SBP >220 were excluded as well as those given tPA.
Godwin SA et al. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med. 2014 Feb; 63: 247-258.
This is a medical literature review of MEDLINE, MEDLINE InProcess, Cochrane Systemic Review Database, and Cochrane Database of Clinical Trials to review the clinical policy for procedural sedation and analgesia in the ED. Procedural sedation is defined as a “treatment strategy for the administration of sedative or analgesic medications to intentionally suppress a patient’s level of consciousness”. The results of the outcome answered four important questions based on procedural sedation such as: (1) in patients undergoing procedural sedation and analgesia in the emergency department, does pre-procedural fasting demonstrate a reduction in the risk of emesis or aspiration?; (2) in patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?; (3) in patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?; (4) inpatients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil and remifentanil be safely administered? Based on this literature review, the evidence was graded, and general recommendations were then provided based on clinical evidence ranging from Level A recommendations (generally accepted recommendations that represent a high degree of clinical certainty), Level B Recommendations (recommendations based on moderate clinical certainty) to Level C Recommendations (recommendations based in the absence of any adequate published literature). This study reviewed the literature of Roback et. al, Treston, Babl et. al and concluded that in regards to patients undergoing procedural sedation and analgesia in the ED, pre-procedural fasting in reducing the risk of emesis or aspiration is a Level B recommendation. This indicates that there should not be a delay in procedural sedation in the ED based on fasting time and that pre-procedural fasting has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia. In reviewing the literature of Lightdale et al, Qadeer et al, Deitch et al, Waugh et al, the study concluded that in regards to patients undergoing procedural sedation, the routine use of capnography to reduce the incidence of adverse respiratory events has a Level B recommendation, and it states that capnography may be used in adjunct to pulse oximetry to detect apnea and hypoventilation. In regards to the minimal number of staff in performing a procedural sedation, this study has a Level C recommendation when it reviewed the literature of Sacchetti et al, Hogan et al, and Vinson and Hoehn. Furthermore, the literature review does not provide clear evidence on the number and type of personnel necessary to safely provide procedural sedation and analgesia. Lastly, in patients undergoing procedural sedation, this study shows a Level A recommendation for using ketamine safely in children and propofol safely in children and adults. The combination of propofol and ketamine can be safely used in children and adults with a Level B recommendation. The sole administration of ketamine for procedural sedation in adults received a Level C recommendation. This clinical policy may assist and inform emergency physicians in the practice of procedural sedation and analgesia.